=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205449782
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT HEALTH AND WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2020
-----------------------------------------------------
Last Update Date | 08/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6200 WOODLAND AVE 62ND WOODLAND AVE. WOODLAND VILLAGE SHOPPING CENTER
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-850-1649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6200 WOODLAND AVE 62ND WOODLAND AVE. WOODLAND VILLAGE SHOPPING CENTER
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-850-1649
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES.
-----------------------------------------------------
Name | WAYNE OLIVER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-850-1649
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0401X
-----------------------------------------------------
Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------