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General NPI Number Information
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NPI Number | 1811532500
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Entity Type | Organization
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Legal Business Name | ALPHA WAVE HEALTH CENTERS LLC
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Dates
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Enumeration Date | 11/17/2019
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Last Update Date | 11/17/2019
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Provider Practice Location Address
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Address Line | 10 WATERSIDE DR STE 101
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City | FARMINGTON
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State | CT
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Zip | 06032-3056
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Country | US
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Telephone | 860-798-0555
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Fax |
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Provider Business Mailing Address
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Address Line | 101 E TOWN PL STE 100
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City | ST AUGUSTINE
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State | FL
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Zip | 32092-2726
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GORAN MLADEN
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Credential |
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Telephone | 386-871-1975
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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