Provider Demographics
NPI:1245936301
Name:KOROMA FAMILY WELLNESS LLC
Entity type:Organization
Organization Name:KOROMA FAMILY WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-577-4850
Mailing Address - Street 1:1457 W SOUTHERN AVE STE A3
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-4813
Mailing Address - Country:US
Mailing Address - Phone:602-838-9434
Mailing Address - Fax:
Practice Address - Street 1:1457 W SOUTHERN AVE STE A3
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4813
Practice Address - Country:US
Practice Address - Phone:602-838-9434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-31
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)