Provider Demographics
NPI:1881475556
Name:WELL WATERED PLACE LLC
Entity type:Organization
Organization Name:WELL WATERED PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JIMEKA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-800-7301
Mailing Address - Street 1:739 HIGH ST # 112
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3425
Mailing Address - Country:US
Mailing Address - Phone:757-800-7301
Mailing Address - Fax:
Practice Address - Street 1:739 HIGH ST # 112
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3425
Practice Address - Country:US
Practice Address - Phone:757-800-7301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health