Healthcare Provider Details

I. General information

NPI: 1699268672
Provider Name (Legal Business Name): WELLNESSCONNECT HEALTHCARE AND PREVENTIVE MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 06/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 GALLATIN ST SW
HUNTSVILLE AL
35801-4510
US

IV. Provider business mailing address

2011 GALLATIN ST SW
HUNTSVILLE AL
35801-4510
US

V. Phone/Fax

Practice location:
  • Phone: 256-907-2493
  • Fax: 256-281-8134
Mailing address:
  • Phone: 256-907-2493
  • Fax: 256-907-1726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD13209
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License NumberMD13209
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number00013209
License Number StateAL

VIII. Authorized Official

Name: JACKIE COPELAND
Title or Position: BILLING MANAGER/CREDENTIALING
Credential: CPC
Phone: 256-907-2493