Basic Information
| Provider Information | |||||||||
| NPI: | 1114420353 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE WELLNESS PLAN MEDICAL CENTERS | ||||||||
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| OtherOrganizationName: | THE WELLNESS PLAN-KEYS GRACE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7700 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132028660 | ||||||||
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| Practice Location | |||||||||
| Address1: | 27321 HAMPDEN ST RM 202 | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480713113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132028660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2018 | ||||||||
| LastUpdateDate: | 07/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | ATWATER | ||||||||
| AuthorizedOfficialFirstName: | SHERRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMPLIANCE AND CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 3132028500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE WELLNESS PLAN MEDICAL CENTERS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0M37210 | 05 | MI | MEDICAID |