Healthcare Provider Details

I. General information

NPI: 1639927296
Provider Name (Legal Business Name): TWO ROADS WELLNESS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 4TH ST
COVINGTON IN
47932-1274
US

IV. Provider business mailing address

3545 N VERMILION ST
DANVILLE IL
61832-1100
US

V. Phone/Fax

Practice location:
  • Phone: 765-231-4193
  • Fax:
Mailing address:
  • Phone: 217-651-6801
  • Fax: 217-651-6802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA NEMECZ
Title or Position: OWNER
Credential:
Phone: 217-651-6801