Basic Information
| Provider Information | |||||||||
| NPI: | 1235651381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE WELLNESS PLAN MEDICAL CENTERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE WELLNESS PLAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7700 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132028660 | ||||||||
| FaxNumber: | 3132028653 | ||||||||
| Practice Location | |||||||||
| Address1: | 46156 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483425033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488970900 | ||||||||
| FaxNumber: | 2488586499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2017 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO & EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3132028550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 122300000X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 163WG0000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | General Practice | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | MI | PER WPS | OTHER | 1235651381 | 01 | PER WPS | OTHER |