Healthcare Provider Details

I. General information

NPI: 1619591179
Provider Name (Legal Business Name): BLACK WELLNESS & PROSPERITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2020
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 CALAVERAS ST
FRESNO CA
93721-1103
US

IV. Provider business mailing address

2201 CALAVERAS ST
FRESNO CA
93721-1103
US

V. Phone/Fax

Practice location:
  • Phone: 559-478-5912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: SHANTAY RENEE DAVIES-BALCH
Title or Position: PRESIDENT & CEO
Credential:
Phone: 559-790-1905