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General NPI Number Information
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NPI Number | 1255526224
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Entity Type | Organization
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Legal Business Name | WELLLIFE:A DIABETES CLINIC AND EDUCATIONAL RESOURCE CENTER
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Dates
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Enumeration Date | 09/12/2007
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Last Update Date | 01/30/2009
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Provider Practice Location Address
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Address Line | 331 TRYON RD STE 103A
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City | RALEIGH
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State | NC
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Zip | 27603-3583
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Country | US
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Telephone | 919-624-6533
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Fax |
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Provider Business Mailing Address
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Address Line | 331 TRYON RD STE 103A
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City | RALEIGH
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State | NC
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Zip | 27603-3583
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Country | US
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Telephone | 919-624-6533
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. DWAN THOMPSON KELSEY
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Credential | NURSE PRACTITIONER
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Telephone | 919-624-6533
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 900229
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License Number State | NC
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