1891899852 NPI number — THE WELLNESS PLAN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891899852 NPI number — THE WELLNESS PLAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE WELLNESS PLAN
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:
1891899852
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21040 GREENFIELD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48237-3025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-967-6604
Provider Business Mailing Address Fax Number:
248-967-6506

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21040 GREENFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48237-3025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-967-6604
Provider Business Practice Location Address Fax Number:
248-967-6506
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHAMMAS
Authorized Official First Name:
NABIL
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY SUPERVISOR
Authorized Official Telephone Number:
248-967-6604

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 5301003783 , 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: 2043167 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1887996 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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