Provider Demographics
NPI:1750064358
Name:WELLNESS WAGON LLC
Entity type:Organization
Organization Name:WELLNESS WAGON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUWAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:FESSHATSION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-230-1582
Mailing Address - Street 1:1113 ABRAMS RD APT 161
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-5516
Mailing Address - Country:US
Mailing Address - Phone:605-230-1582
Mailing Address - Fax:
Practice Address - Street 1:1113 ABRAMS RD APT 161
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-5516
Practice Address - Country:US
Practice Address - Phone:605-230-1582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-09
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)