Healthcare Provider Details

I. General information

NPI: 1568692135
Provider Name (Legal Business Name): ELITE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 HYDE PARK AVE SUITE 4
JAMAICA PLAIN MA
02130-4163
US

IV. Provider business mailing address

18 HYDE PARK AVE SUITE 4
JAMAICA PLAIN MA
02130-4163
US

V. Phone/Fax

Practice location:
  • Phone: 617-522-4397
  • Fax:
Mailing address:
  • Phone: 617-522-4397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: MISHELL RONICA BROOKINS
Title or Position: PRESIDENT
Credential:
Phone: 617-522-4397