Provider Demographics
NPI:1649966607
Name:SURRENDER WELLNESS CENTER
Entity type:Organization
Organization Name:SURRENDER WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LINCOLN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:602-716-1821
Mailing Address - Street 1:4949 E VANBUREN UNIT #61024
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1206 E HIGHLAND AVE UNIT 205
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4053
Practice Address - Country:US
Practice Address - Phone:602-716-1821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder