Healthcare Provider Details

I. General information

NPI: 1184431280
Provider Name (Legal Business Name): FIRST LIGHT WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6463 PROPRIETORS RD STE 201
WORTHINGTON OH
43085-3263
US

IV. Provider business mailing address

6463 PROPRIETORS RD STE 201
WORTHINGTON OH
43085-3263
US

V. Phone/Fax

Practice location:
  • Phone: 513-629-0040
  • Fax:
Mailing address:
  • Phone: 513-629-0040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code364SP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State

VIII. Authorized Official

Name: PAUL KYEI
Title or Position: PRACTICE OWNER
Credential:
Phone: 513-629-0040