Provider Demographics
NPI:1568692135
Name:ELITE WELLNESS
Entity Type:Organization
Organization Name:ELITE WELLNESS
Other - Org Name:ELITE WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MISHELL
Authorized Official - Middle Name:RONICA
Authorized Official - Last Name:BROOKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-522-4397
Mailing Address - Street 1:18 HYDE PARK AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-4163
Mailing Address - Country:US
Mailing Address - Phone:617-522-4397
Mailing Address - Fax:
Practice Address - Street 1:18 HYDE PARK AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4163
Practice Address - Country:US
Practice Address - Phone:617-522-4397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-17
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty