1043373244 NPI number — THE WELLNESS PLAN MEDICAL CENTERS

Table of content: (NPI 1043373244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043373244 NPI number — THE WELLNESS PLAN MEDICAL CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE WELLNESS PLAN MEDICAL CENTERS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE WELLNESS PLAN MEDICAL CENTERS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043373244
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7700 2ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48202-2477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-202-8660
Provider Business Mailing Address Fax Number:
313-202-8653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2888 W GRAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-875-4200
Provider Business Practice Location Address Fax Number:
313-875-5611
Provider Enumeration Date:
12/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
V.
Authorized Official Title or Position:
CEO AND EXEC DIR
Authorized Official Telephone Number:
313-202-8550

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23-1927 . This is a "FQHC LOOK A LIKE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".