Healthcare Provider Details

I. General information

NPI: 1124456330
Provider Name (Legal Business Name): THE WELLNESS CLINIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2013
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1281 MARINETTE AVE
MARINETTE WI
54143-2018
US

IV. Provider business mailing address

1281 MARINETTE AVE
MARINETTE WI
54143-2018
US

V. Phone/Fax

Practice location:
  • Phone: 715-735-5500
  • Fax: 715-735-5502
Mailing address:
  • Phone: 715-735-5500
  • Fax: 715-735-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON KOENIGS
Title or Position: PRESIDENT AND CFO
Credential: PT
Phone: 715-735-5500