MEDICARE: REVERSE TIME WELLNESS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1003611187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVERSE TIME WELLNESS INC

Provider Business Mailing Address
First Line	:	1086 LONG RIDGE RD
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06903-4404
Country	:	US
Telephone Number	:	203-274-7426
Fax Number	:	203-274-7426

Provider Business Practice Location Address
First Line	:	1086 LONG RIDGE RD
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06903-4404
Country	:	US
Telephone Number	:	203-274-7426
Fax Number	:	203-274-7426

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NEISHELLE WALCOTT
Credential	:	PA
Telephone Number	:	203-274-7426

Provider Enumeration Date	:	02/13/2025
Last Update Date	:	04/08/2025

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Directions to “REVERSE TIME WELLNESS INC ” Practice Location

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