Healthcare Provider Details

I. General information

NPI: 1710681465
Provider Name (Legal Business Name): MICHIGAN WELLNESS ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2023
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5816 N SHELDON RD
CANTON MI
48187-3153
US

IV. Provider business mailing address

2019 WASHTENAW AVE UNIT 5403
ANN ARBOR MI
48104-3656
US

V. Phone/Fax

Practice location:
  • Phone: 858-775-1700
  • Fax:
Mailing address:
  • Phone: 858-775-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PATRICK THOMAS WATERS
Title or Position: VICE PRESIDENT
Credential:
Phone: 858-775-1700