=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013410596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUR WELLNESS HUB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2018
-----------------------------------------------------
Last Update Date | 03/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17401 E 10 MILE RD
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-1256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-336-9355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17401 E 10 MILE RD
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-1256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-336-9355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | LATRESHA PATMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 917-288-4772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------