Basic Information
Provider Information | |||||||||
NPI: | 1497065478 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIONEER HEALTH ALLIANCE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WELLNESS ON WHEELS, INC. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1580 SANTA BARBARA BLVD | ||||||||
Address2: |   | ||||||||
City: | THE VILLAGES | ||||||||
State: | FL | ||||||||
PostalCode: | 321596827 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3525081125 | ||||||||
FaxNumber: | 3526744386 | ||||||||
Practice Location | |||||||||
Address1: | 1580 SANTA BARBARA BLVD | ||||||||
Address2: |   | ||||||||
City: | THE VILLAGES | ||||||||
State: | FL | ||||||||
PostalCode: | 321596827 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3525081125 | ||||||||
FaxNumber: | 3526744386 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2010 | ||||||||
LastUpdateDate: | 04/13/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KHANNA | ||||||||
AuthorizedOfficialFirstName: | SEEMA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/OPERATOR | ||||||||
AuthorizedOfficialTelephone: | 3525163972 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 010139401 | 05 | FL |   | MEDICAID | EY818A | 01 | FL | MEDICARE PTAN | OTHER |