Provider Demographics
NPI:1376941203
Name:WILLIAMSVILLE WELLNESS, LLC
Entity type:Organization
Organization Name:WILLIAMSVILLE WELLNESS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WOODROW
Authorized Official - Last Name:CABANISS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:804-559-9959
Mailing Address - Street 1:10515 CABANISS LN
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:VA
Mailing Address - Zip Code:23069-1840
Mailing Address - Country:US
Mailing Address - Phone:804-559-9959
Mailing Address - Fax:804-559-9613
Practice Address - Street 1:8505 BELL CREEK RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-3829
Practice Address - Country:US
Practice Address - Phone:804-559-9959
Practice Address - Fax:804-559-9613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA994251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health