Basic Information
Provider Information | |||||||||
NPI: | 1386684033 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE WELLNESS PLAN MEDICAL CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE WELLNESS PLAN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7700 2ND AVE | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482022477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3132028660 | ||||||||
FaxNumber: | 3132028653 | ||||||||
Practice Location | |||||||||
Address1: | 4909 E OUTER DR | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482343446 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3133662000 | ||||||||
FaxNumber: | 3133693950 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 08/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KING | ||||||||
AuthorizedOfficialFirstName: | ANTHONY | ||||||||
AuthorizedOfficialMiddleName: | V | ||||||||
AuthorizedOfficialTitleorPosition: | CEO & EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3132028550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X |   |   | N |   | Suppliers | Pharmacy |   | 3336C0003X | 5301003705 | MI | Y |   | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
ID | Type | State | Issuer | Description | 2043107 | 01 |   | PK | OTHER | 1887996 | 05 | MI |   | MEDICAID |