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NPI Code Detail

MEDICARE: BLACK ELEPHANT WELLNESS CO LLC

MEDICARE: BLACK ELEPHANT WELLNESS CO LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101Y00000XCounselor

General Provider Information

NPI Number : 1649125212
Entity Type Code : Organization
Provider Name (Legal Business Name) : BLACK ELEPHANT WELLNESS CO LLC
Provider Business Mailing Address
First Line : 5589 DUNHAM RD
Second Line :
City : MAPLE HEIGHTS
State : OH
Zip : 44137-3657
Country : US
Telephone Number : 216-626-7648
Fax Number :
Provider Business Practice Location Address
First Line : 5589 DUNHAM RD
Second Line :
City : MAPLE HEIGHTS
State : OH
Zip : 44137-3657
Country : US
Telephone Number : 216-626-7648
Fax Number :
Authorized Official
Title or Position : OWNER
Name : JAMILA PROVITT
Credential :
Telephone Number : 216-626-7648
Provider Enumeration Date : 02/28/2026
Last Update Date : 02/28/2026

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Directions to “BLACK ELEPHANT WELLNESS CO LLC ” Practice Location

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