Basic Information
| Provider Information | |||||||||
| NPI: | 1366051708 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SENIOR WELLNESS GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 AUBURN DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403436955 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2473 NORTH RD NE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444833054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303722251 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2020 | ||||||||
| LastUpdateDate: | 07/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | NEAL | ||||||||
| AuthorizedOfficialFirstName: | KERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4403436955 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X | Y | Managed Care Organizations | Point of Service |
No ID Information.