Provider Demographics
NPI:1114400785
Name:THEWELL
Entity Type:Organization
Organization Name:THEWELL
Other - Org Name:UPLIFT ATHLETICS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/FOUNDRESS
Authorized Official - Prefix:MS
Authorized Official - First Name:CAMILLA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:313-283-8620
Mailing Address - Street 1:28150 TAVISTOCK TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5180
Mailing Address - Country:US
Mailing Address - Phone:313-283-8620
Mailing Address - Fax:
Practice Address - Street 1:28150 TAVISTOCK TRL
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-5180
Practice Address - Country:US
Practice Address - Phone:313-283-8620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise PhysiologistGroup - Multi-Specialty