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General NPI Number Information
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NPI Number | 1154661395
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Entity Type | Organization
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Legal Business Name | PRIME WELLNESS CLINIC LLC
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Dates
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Enumeration Date | 02/25/2013
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Last Update Date | 09/14/2017
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Provider Practice Location Address
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Address Line | 14904 JEFFERSON DAVIS HWY SUITE 305
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3908
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Country | US
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Telephone | 571-492-7702
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Fax | 571-492-7704
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Provider Business Mailing Address
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Address Line | 14904 JEFFERSON DAVIS HWY SUITE 305
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City | WOODBRIDGE
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State | VA
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Zip | 22191-3908
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Country | US
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Telephone | 571-492-7702
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Fax | 571-492-7704
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Authorized Official
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Title or Position | PROPRIETOR
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Name | DR. ABUBAKARI WELLE
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Credential | M.D
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Telephone | 703-598-6146
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 0101245731
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License Number State | VA
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