Provider Demographics
NPI:1669874335
Name:TIME OUT WELLNESS CENTER & DAY SPA
Entity type:Organization
Organization Name:TIME OUT WELLNESS CENTER & DAY SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:YEARICK
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:570-748-4505
Mailing Address - Street 1:108 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-1625
Mailing Address - Country:US
Mailing Address - Phone:570-748-4505
Mailing Address - Fax:
Practice Address - Street 1:108 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-1625
Practice Address - Country:US
Practice Address - Phone:570-748-4505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG004415261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center