Provider Demographics
NPI: | 1467344093 |
---|---|
Name: | GOLAN BRIDGE WELLNESS CENTER LLC |
Entity type: | Organization |
Organization Name: | GOLAN BRIDGE WELLNESS CENTER LLC |
Other - Org Name: | <UNAVAIL> |
Other - Org Type: | |
Authorized Official - Title/Position: | MANGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | GABADIAH |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MCCLAY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 404-820-9900 |
Mailing Address - Street 1: | 440 MONTICELLO AVE STE 1867 |
Mailing Address - Street 2: | |
Mailing Address - City: | NORFOLK |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 23510-2571 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 757-346-2110 |
Mailing Address - Fax: | 757-687-9927 |
Practice Address - Street 1: | 440 MONTICELLO AVE STE 1867 |
Practice Address - Street 2: | |
Practice Address - City: | NORFOLK |
Practice Address - State: | VA |
Practice Address - Zip Code: | 23510-2571 |
Practice Address - Country: | US |
Practice Address - Phone: | 757-346-2110 |
Practice Address - Fax: | 757-687-9927 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2025-07-17 |
Last Update Date: | 2025-08-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |