Provider Demographics
NPI:1649218215
Name:WILSON WELLNESS GROUP
Entity Type:Organization
Organization Name:WILSON WELLNESS GROUP
Other - Org Name:BELLA HOME MEDICAL AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BALKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-217-1976
Mailing Address - Street 1:4625 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-3323
Mailing Address - Country:US
Mailing Address - Phone:262-657-3333
Mailing Address - Fax:262-657-6201
Practice Address - Street 1:4625 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-3323
Practice Address - Country:US
Practice Address - Phone:262-657-3333
Practice Address - Fax:262-657-6201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5539340001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI417553300Medicaid
WI5539340001Medicare NSC