Provider Demographics
NPI:1649788134
Name:BEDFORD WELLNESS CENTER LLC
Entity type:Organization
Organization Name:BEDFORD WELLNESS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-310-5001
Mailing Address - Street 1:342 S RICHARD ST
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15522-1743
Mailing Address - Country:US
Mailing Address - Phone:814-623-8414
Mailing Address - Fax:814-623-6668
Practice Address - Street 1:342 S RICHARD ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:PA
Practice Address - Zip Code:15522-1743
Practice Address - Country:US
Practice Address - Phone:814-623-8414
Practice Address - Fax:814-623-6668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009365-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018649730001Medicaid