MEDICARE: WELLNESS CONSULTATION SERVICES 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	261QM1300X	Multi-Specialty Clinic/Center	00634638	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	053650	OTHER	NJ	MEDICARE PROVIDER NUMBER

General Provider Information

NPI Number	:	1306089792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS CONSULTATION SERVICES LLC

Provider Business Mailing Address
First Line	:	6 ASPEN CT
Second Line	:
City	:	EAST BRUNSWICK
State	:	NJ
Zip	:	08816-3345
Country	:	US
Telephone Number	:	732-816-1651
Fax Number	:	732-238-9509

Provider Business Practice Location Address
First Line	:	8 OLD BRIDGE TPKE
Second Line	:
City	:	SOUTH RIVER
State	:	NJ
Zip	:	08882-2400
Country	:	US
Telephone Number	:	732-390-4888
Fax Number	:	732-390-0255

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. BETSY ROCHELLE DUBOV
Credential	:	REGISTERED DIETITIAN
Telephone Number	:	732-816-1651

Provider Enumeration Date	:	04/14/2009
Last Update Date	:	04/14/2009

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Directions to “WELLNESS CONSULTATION SERVICES LLC ” Practice Location

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