=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295039899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS CENTER OF MICHIGAN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2010
-----------------------------------------------------
Last Update Date | 12/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17336 W 12 MILE RD STE 102
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-943-8860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17336 W 12 MILE RD STE 102
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-943-8860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DIMPLE TRIPATHI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-943-8860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 4301041657
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------