MEDICARE: WELLSPRING COMPREHENSIVE MANAGEMENT COMPANY, LLC.

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	363L00000X	Nurse Practitioner	4704203961	MI

General Provider Information

NPI Number	:	1881948594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSPRING COMPREHENSIVE MANAGEMENT COMPANY, LLC.

Provider Business Mailing Address
First Line	:	19785 W 12 MILE RD # 354
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-2584
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	19785 W 12 MILE RD # 354
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-2584
Country	:	US
Telephone Number	:	248-224-5316
Fax Number	:	248-629-9194

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DR. KAREN L. BOYD
Credential	:	DNP, NP-C
Telephone Number	:	248-224-5316

Provider Enumeration Date	:	11/02/2012
Last Update Date	:	09/08/2013

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