Healthcare Provider Details

I. General information

NPI: 1639903123
Provider Name (Legal Business Name): URBAN WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 RUSS ST FL 3
HARTFORD CT
06106-1520
US

IV. Provider business mailing address

36 RUSS ST FL 3
HARTFORD CT
06106-1520
US

V. Phone/Fax

Practice location:
  • Phone: 860-292-0030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DESTINY TYSON
Title or Position: OWNER
Credential:
Phone: 860-292-0030