Provider Demographics
NPI:1952087637
Name:MAPO WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:MAPO WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HORTENSE
Authorized Official - Middle Name:
Authorized Official - Last Name:BISSILA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:901-800-1037
Mailing Address - Street 1:8225 ROCKCREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-4594
Mailing Address - Country:US
Mailing Address - Phone:901-800-1037
Mailing Address - Fax:
Practice Address - Street 1:4494 W PEORIA AVE STE 13-115A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-2023
Practice Address - Country:US
Practice Address - Phone:901-800-1037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty