Healthcare Provider Details

I. General information

NPI: 1538894225
Provider Name (Legal Business Name): ELK RAPIDS WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9060 N BAYSHORE DR STE B
ELK RAPIDS MI
49629-9436
US

IV. Provider business mailing address

9060 N BAYSHORE DR STE B
ELK RAPIDS MI
49629-9436
US

V. Phone/Fax

Practice location:
  • Phone: 231-498-4552
  • Fax:
Mailing address:
  • Phone: 231-498-4552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MAUREEN REYNOLDS STREET
Title or Position: PHYSICIAN
Credential: MD
Phone: 231-944-9093