MEDICARE: MD WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335G00000X	Medical Foods Supplier	L17000121902	FL

General Provider Information

NPI Number	:	1194240606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MD WELLNESS LLC

Provider Business Mailing Address
First Line	:	28373 DEQUINDRE RD
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-3003
Country	:	US
Telephone Number	:	313-209-3353
Fax Number	:	313-406-7255

Provider Business Practice Location Address
First Line	:	28373 DEQUINDRE RD
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-3003
Country	:	US
Telephone Number	:	313-209-3353
Fax Number	:	313-406-7255

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MRS. VANDANA RAMAIAH
Credential	:	MS
Telephone Number	:	727-687-9102

Provider Enumeration Date	:	08/04/2017
Last Update Date	:	07/21/2022

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Directions to “MD WELLNESS LLC ” Practice Location

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