=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104980614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLLIFE NETWORK INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2006
-----------------------------------------------------
Last Update Date | 12/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2614 BELL BLVD
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11360-2539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-224-7843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 142-02 20TH AVENUE
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11351-9712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-559-0516
-----------------------------------------------------
Fax | 718-762-6140
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MRS. LORI ALAMEDA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 347-542-5616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | 01260677
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------