Basic Information
| Provider Information | |||||||||
| NPI: | 1417315466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEAM WELLNESS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 921 HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48124 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 14799 DIX-TOLEDO RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343248326 | ||||||||
| FaxNumber: | 7343248327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2016 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | SOUTH | ||||||||
| AuthorizedOfficialFirstName: | AMALIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | HUMAN RESOURCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3132743700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.