Basic Information
| Provider Information | |||||||||
| NPI: | 1649229287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE WELLNESS PLAN MEDICAL CENTERS | ||||||||
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| OtherOrganizationName: | THE WELLNESS PLAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2888 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022612 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2888 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138754200 | ||||||||
| FaxNumber: | 3138755611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO & EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3132028660 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301038485 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1720123029 | 01 | MI | NPI | OTHER | 5078418 | 05 | MI | MEDICAID |