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General NPI Number Information
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NPI Number | 1679523278
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Entity Type | Organization
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Legal Business Name | NEW IMAGE BODY AND WELLNESS CLINIC, PC
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Dates
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Enumeration Date | 05/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2590 ELIZABETH LAKE RD
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City | WATERFORD
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State | MI
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Zip | 48328-3314
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Country | US
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Telephone | 248-682-6627
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Fax |
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Provider Business Mailing Address
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Address Line | 1396 SCOTT LAKE RD
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City | WATERFORD
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State | MI
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Zip | 48328-1578
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Country | US
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Telephone | 248-682-6627
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Fax |
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Authorized Official
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Title or Position | FAMILY NURSE PRACTITIONER
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Name | MRS. BARBARA JEAN KACEL
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Credential | FNP-C
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Telephone | 248-682-6627
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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 | 06914E
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License Number State | MI
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