Provider Demographics
NPI:1649045451
Name:OLD FORGE WELLNESS LLC
Entity type:Organization
Organization Name:OLD FORGE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SLOCUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:570-774-4171
Mailing Address - Street 1:821 S MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1497
Mailing Address - Country:US
Mailing Address - Phone:570-774-4171
Mailing Address - Fax:570-457-3220
Practice Address - Street 1:821 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1497
Practice Address - Country:US
Practice Address - Phone:570-774-4171
Practice Address - Fax:570-457-3220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty