Healthcare Provider Details

I. General information

NPI: 1255669792
Provider Name (Legal Business Name): MOBILE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

373 ADAMS CT
FERNDALE MI
48220-2423
US

IV. Provider business mailing address

PO BOX 781
SOUTHFIELD MI
48037-0781
US

V. Phone/Fax

Practice location:
  • Phone: 248-547-3260
  • Fax:
Mailing address:
  • Phone: 248-547-3260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number5901001148
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number5901001148
License Number StateMI

VIII. Authorized Official

Name: DR. DENISE BRADFORD HENRY
Title or Position: DIRECTOR
Credential: DPM
Phone: 248-792-1316