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General NPI Number Information
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NPI Number | 1003611187
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Entity Type | Organization
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Legal Business Name | REVERSE TIME WELLNESS INC
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Dates
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Enumeration Date | 02/13/2025
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Last Update Date | 04/08/2025
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Provider Practice Location Address
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Address Line | 1086 LONG RIDGE RD
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City | STAMFORD
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State | CT
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Zip | 06903-4404
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Country | US
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Telephone | 203-274-7426
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Fax | 203-274-7426
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Provider Business Mailing Address
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Address Line | 1086 LONG RIDGE RD
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City | STAMFORD
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State | CT
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Zip | 06903-4404
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Country | US
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Telephone | 203-274-7426
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Fax | 203-274-7426
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Authorized Official
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Title or Position | PRESIDENT
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Name | NEISHELLE WALCOTT
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Credential | PA
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Telephone | 203-274-7426
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207PE0004X
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Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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