Basic Information
| Provider Information | |||||||||
| NPI: | 1467817098 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEAM WELLNESS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133965300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2925 RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133965300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2015 | ||||||||
| LastUpdateDate: | 12/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | DOWELL | ||||||||
| AuthorizedOfficialFirstName: | DOWELL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CARE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3133965300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | 1588855100 | MI | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.