Healthcare Provider Details

I. General information

NPI: 1063804136
Provider Name (Legal Business Name): CENTRAL OUTREACH WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 ANDERSON ST
PITTSBURGH PA
15212-5803
US

IV. Provider business mailing address

PO BOX 19425
CLEVELAND OH
44119-0425
US

V. Phone/Fax

Practice location:
  • Phone: 412-608-8313
  • Fax: 412-920-5861
Mailing address:
  • Phone: 412-322-4151
  • Fax: 844-389-1405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STACY LANE
Title or Position: OWNER
Credential: DO
Phone: 412-608-8313