Provider Demographics
NPI:1932745346
Name:ALPHA WAVE HEALTH CENTERS LLC
Entity Type:Organization
Organization Name:ALPHA WAVE HEALTH CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GORAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MLADEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-871-1975
Mailing Address - Street 1:101 E TOWN PL STE 100
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-2726
Mailing Address - Country:US
Mailing Address - Phone:386-763-1400
Mailing Address - Fax:
Practice Address - Street 1:101 E TOWN PL STE 100
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-2726
Practice Address - Country:US
Practice Address - Phone:386-763-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center