Provider Demographics
NPI:1902932353
Name:DIGESTIVE WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:DIGESTIVE WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GHULAM
Authorized Official - Middle Name:N
Authorized Official - Last Name:MIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-753-6643
Mailing Address - Street 1:3939 CLEVELAND MASSILLON RD
Mailing Address - Street 2:
Mailing Address - City:NORTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-5611
Mailing Address - Country:US
Mailing Address - Phone:330-237-1058
Mailing Address - Fax:330-237-1059
Practice Address - Street 1:3939 SOUTH CLEVELAND-MASSILLON ROAD
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:OH
Practice Address - Zip Code:44203
Practice Address - Country:US
Practice Address - Phone:330-237-1058
Practice Address - Fax:330-237-1059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3612341OtherMEDICARE PTAN