Provider Demographics
NPI:1376375386
Name:WELL FIT BEHAVIOR LLC
Entity type:Organization
Organization Name:WELL FIT BEHAVIOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GLOIRE
Authorized Official - Middle Name:DEPARDIEU
Authorized Official - Last Name:MOUGANI
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:614-772-8182
Mailing Address - Street 1:25843 W SHANGRA LA
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85193-7525
Mailing Address - Country:US
Mailing Address - Phone:478-420-0060
Mailing Address - Fax:
Practice Address - Street 1:25843 W SHANGRA LA
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85193-7525
Practice Address - Country:US
Practice Address - Phone:478-420-0060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility