Provider Demographics
NPI:1902262728
Name:WELLNESS CARE CENTER LLC
Entity Type:Organization
Organization Name:WELLNESS CARE CENTER LLC
Other - Org Name:WELLNESS CARE CENTER LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-703-0047
Mailing Address - Street 1:25900 GREENFIELD RD
Mailing Address - Street 2:STE 411
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1292
Mailing Address - Country:US
Mailing Address - Phone:248-703-0047
Mailing Address - Fax:
Practice Address - Street 1:25900 GREENFIELD RD
Practice Address - Street 2:STE 411
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1292
Practice Address - Country:US
Practice Address - Phone:248-703-0047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLNESS CARE CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-08
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
173000000X, 174400000X, 261QP3300X
MI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty