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General NPI Number Information
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NPI Number | 1164221172
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Entity Type | Organization
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Legal Business Name | COMMUNITY CONNECTIONS WELLNESS CENTER LLC
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Dates
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Enumeration Date | 03/11/2025
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Last Update Date | 05/21/2025
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Provider Practice Location Address
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Address Line | 643 S GREAT SOUTHWEST PKWY STE 102&104
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City | GRAND PRAIRIE
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State | TX
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Zip | 75051-1056
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Country | US
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Telephone | 602-907-1719
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Fax |
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Provider Business Mailing Address
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Address Line | 643 S GREAT SOUTHWEST PKWY STE 102&104
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City | GRAND PRAIRIE
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State | TX
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Zip | 75051-1056
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Country | US
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Telephone | 602-907-1719
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | RICHARD K FISHER
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Credential |
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Telephone | 602-907-1719
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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