Healthcare Provider Details

I. General information

NPI: 1174304190
Provider Name (Legal Business Name): CHANGING TIDES WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LINCOLN DR E STE 2
MARLTON NJ
08053-1566
US

IV. Provider business mailing address

199 NORTH WOODBURY RD.
PITMAN NJ
08071
US

V. Phone/Fax

Practice location:
  • Phone: 856-508-0977
  • Fax:
Mailing address:
  • Phone: 856-508-0977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS DESIMONE
Title or Position: CEO/OWNER
Credential: LPC, LCADC
Phone: 856-217-9182