Healthcare Provider Details

I. General information

NPI: 1487393930
Provider Name (Legal Business Name): KUUMBA COMMUNITY HEALTH AND WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 WILLIAMSON ROAD NE
ROANOKE VA
24012
US

IV. Provider business mailing address

3716 MELROSE AVENUE NW
ROANOKE VA
24017
US

V. Phone/Fax

Practice location:
  • Phone: 540-566-3719
  • Fax: 540-204-4288
Mailing address:
  • Phone: 540-655-4948
  • Fax: 540-566-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN STEWART
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 540-362-0360