1508012816 NPI number — WELLLIFE NETWORK INC

Table of content: (NPI 1295036242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508012816 NPI number — WELLLIFE NETWORK INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLLIFE NETWORK INC
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:
PSCH INC.
Provider Other Organization Name Type Code:
4
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:
1508012816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14202 20TH AVE FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLUSHING
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11351-3000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-559-0516
Provider Business Mailing Address Fax Number:
718-762-6140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 ELMONT ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMONT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11003-1603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-542-5667
Provider Business Practice Location Address Fax Number:
347-542-5840
Provider Enumeration Date:
08/18/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
TUCKER
Authorized Official First Name:
SHERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
718-559-0534

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01304109 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".