Healthcare Provider Details

I. General information

NPI: 1922552512
Provider Name (Legal Business Name): KUUMBA COMMUNITY HEALTH & WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 TAZEWELL AVE SE
ROANOKE VA
24013-1445
US

IV. Provider business mailing address

321 TAZEWELL AVE SE
ROANOKE VA
24013-1445
US

V. Phone/Fax

Practice location:
  • Phone: 540-362-0360
  • Fax: 540-362-1448
Mailing address:
  • Phone: 540-362-0360
  • 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: EILEEN G LEPRO
Title or Position: CEO
Credential: MPH
Phone: 540-362-0360