Healthcare Provider Details

I. General information

NPI: 1649125212
Provider Name (Legal Business Name): BLACK ELEPHANT WELLNESS CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 ENTERPRISE PARKWAY SUITE 115
SOLON OH
44139
US

IV. Provider business mailing address

6004 YOUNGSTOWN WARREN RD
NILES OH
44446-4603
US

V. Phone/Fax

Practice location:
  • Phone: 234-600-4300
  • Fax:
Mailing address:
  • Phone: 234-600-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: JAMILA PROVITT
Title or Position: OWNER
Credential:
Phone: 234-600-4300