Provider Demographics
NPI:1649976945
Name:PROVENANCE SUBSTANCE ABUSE & WELLNESS CENTERS LLC
Entity type:Organization
Organization Name:PROVENANCE SUBSTANCE ABUSE & WELLNESS CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVOLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-442-9819
Mailing Address - Street 1:4870 SADLER RD PMB #8903
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4870 SADLER RD PMB #8903
Practice Address - Street 2:SUITE 300
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060
Practice Address - Country:US
Practice Address - Phone:480-442-9819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-07
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder