Healthcare Provider Details

I. General information

NPI: 1629702519
Provider Name (Legal Business Name): ELITE WELLNESS, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2022
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BELMONT RD
NORTH HAVEN CT
06473-3910
US

IV. Provider business mailing address

19 BELMONT RD
NORTH HAVEN CT
06473-3910
US

V. Phone/Fax

Practice location:
  • Phone: 203-927-2191
  • Fax: 325-221-2031
Mailing address:
  • Phone: 203-927-2191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNIFER B LEE
Title or Position: APRN
Credential: APRN
Phone: 203-927-2191