MEDICARE: PROVIVE WELLNESS SCRANTON 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
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1790638567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIVE WELLNESS SCRANTON LLC

Provider Business Mailing Address
First Line	:	15 PERLMAN DR STE 120
Second Line	:
City	:	SPRING VALLEY
State	:	NY
Zip	:	10977-5281
Country	:	US
Telephone Number	:	347-374-1767
Fax Number	:

Provider Business Practice Location Address
First Line	:	1123 CAPOUSE AVE
Second Line	:
City	:	SCRANTON
State	:	PA
Zip	:	18509-2730
Country	:	US
Telephone Number	:	347-374-1767
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	MAYER WEBER
Credential	:
Telephone Number	:	347-374-1767

Provider Enumeration Date	:	02/19/2026
Last Update Date	:	02/19/2026

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