Healthcare Provider Details

I. General information

NPI: 1386456317
Provider Name (Legal Business Name): EMPYREAN OASIS WELLNESS CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MAYLAND DR STE 5259
RICHMOND VA
23294-4648
US

IV. Provider business mailing address

8401 MAYLAND DR STE 5259
RICHMOND VA
23294-4648
US

V. Phone/Fax

Practice location:
  • Phone: 618-310-8306
  • Fax:
Mailing address:
  • Phone: 618-310-8306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. LATOYA PAULETTE
Title or Position: DIRECTOR
Credential: LCSW
Phone: 323-506-9714