Healthcare Provider Details

I. General information

NPI: 1699029884
Provider Name (Legal Business Name): KUUMBA COMM HEALTH & WELLNESS CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2012
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3716 MELROSE AVE NW SUITE 130
ROANOKE VA
24017-2716
US

IV. Provider business mailing address

3716 MELROSE AVE NW SUITE 130
ROANOKE VA
24017-2716
US

V. Phone/Fax

Practice location:
  • Phone: 540-283-2552
  • Fax: 540-283-2544
Mailing address:
  • Phone: 540-283-2552
  • Fax: 540-283-2544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201004488
License Number StateVA

VIII. Authorized Official

Name: MS. EILEEN G LEPRO
Title or Position: CEO
Credential:
Phone: 540-362-5158