Healthcare Provider Details

I. General information

NPI: 1205815420
Provider Name (Legal Business Name): KUUMBA COMMUNITY HEALTH & WELLNESS CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3716 MELROSE AVE NW
ROANOKE VA
24017-2716
US

IV. Provider business mailing address

3716 MELROSE AVE NW
ROANOKE VA
24017-2716
US

V. Phone/Fax

Practice location:
  • Phone: 540-362-5158
  • Fax: 540-362-1448
Mailing address:
  • Phone: 540-362-5158
  • Fax: 540-362-1448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MS. JONATHAN STEWART
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 540-861-1263