Healthcare Provider Details

I. General information

NPI: 1902724255
Provider Name (Legal Business Name): WELLWARD VITALITY SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 E MAIN ST
LANSDALE PA
19446-2520
US

IV. Provider business mailing address

223 E MAIN ST
LANSDALE PA
19446-2520
US

V. Phone/Fax

Practice location:
  • Phone: 267-694-0617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN CHISHOLM
Title or Position: OWNER/ MANAGING MEMBER
Credential:
Phone: 267-694-0617