Provider Demographics
NPI:1396268405
Name:HER WELLNESS HEALTH CENTER LLC
Entity type:Organization
Organization Name:HER WELLNESS HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KIKELOMO
Authorized Official - Middle Name:
Authorized Official - Last Name:OTUYELU-GARRITANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-523-3469
Mailing Address - Street 1:19 GROUND PINE RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-1917
Mailing Address - Country:US
Mailing Address - Phone:914-523-3469
Mailing Address - Fax:
Practice Address - Street 1:65 OLD RIDGEFIELD RD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897-3018
Practice Address - Country:US
Practice Address - Phone:203-665-0900
Practice Address - Fax:203-665-0899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT047101207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004213865Medicaid