=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215752670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORE WELLNESS CENTERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2024
-----------------------------------------------------
Last Update Date | 11/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2952 KENSINGTON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19134-3017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-432-7396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 MARKET ST STE 1200
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19102-1932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-419-5842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DUANE LASSITER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-432-7396
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------