Healthcare Provider Details

I. General information

NPI: 1497265243
Provider Name (Legal Business Name): CHOICE WELLNESS CENTERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 12/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 C STREET SUITE 102
VANCOUVER WA
98663
US

IV. Provider business mailing address

1610 C ST STE 102
VANCOUVER WA
98663-3400
US

V. Phone/Fax

Practice location:
  • Phone: 360-787-2125
  • Fax: 360-787-2625
Mailing address:
  • Phone: 360-787-2125
  • Fax: 360-787-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60494259
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberMD60120618
License Number StateWA

VIII. Authorized Official

Name: DR. ESTELA UY CLEMENTE
Title or Position: CEO
Credential: PHARM.D.
Phone: 360-787-2902