MEDICARE: NEW IMAGE BODY AND WELLNESS CLINIC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1275559379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW IMAGE BODY AND WELLNESS CLINIC

Provider Business Mailing Address
First Line	:	1396 SCOTT LAKE RD
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48328-1578
Country	:	US
Telephone Number	:	248-563-3775
Fax Number	:

Provider Business Practice Location Address
First Line	:	1396 SCOTT LAKE RD
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48328-1578
Country	:	US
Telephone Number	:	248-563-3775
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROSLYN THOMPSON
Credential	:
Telephone Number	:	248-563-3775

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	08/22/2020

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