Provider Demographics
NPI:1255669792
Name:MOBILE WELLNESS
Entity Type:Organization
Organization Name:MOBILE WELLNESS
Other - Org Name:MOBILE WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-792-1316
Mailing Address - Street 1:PO BOX 781
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-0781
Mailing Address - Country:US
Mailing Address - Phone:248-547-3260
Mailing Address - Fax:
Practice Address - Street 1:373 ADAMS CT
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-2423
Practice Address - Country:US
Practice Address - Phone:248-547-3260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001148261QP1100X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No335E00000XSuppliersProsthetic/Orthotic Supplier