Provider Demographics
NPI:1649467846
Name:POZEGA WELLNESS CENTER INC
Entity type:Organization
Organization Name:POZEGA WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:POZEGA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-925-7001
Mailing Address - Street 1:5324 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2222
Mailing Address - Country:US
Mailing Address - Phone:304-925-7001
Mailing Address - Fax:304-925-7234
Practice Address - Street 1:5324 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2222
Practice Address - Country:US
Practice Address - Phone:304-925-7001
Practice Address - Fax:304-925-7234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1512208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0111573001Medicaid