Healthcare Provider Details

I. General information

NPI: 1154712271
Provider Name (Legal Business Name): WELLNESS NETWORKS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 VICTOR ST
HIGHLAND PARK MI
48203-3128
US

IV. Provider business mailing address

DEPT CH 14583
PALATINE IL
60055-0001
US

V. Phone/Fax

Practice location:
  • Phone: 313-446-9800
  • Fax: 313-446-9839
Mailing address:
  • Phone: 866-525-5484
  • Fax: 833-394-4961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TANYA MAULDIN
Title or Position: PROVIDER ENROLLMENT MANGER
Credential:
Phone: 414-225-1611