Provider Demographics
NPI:1689453250
Name:WELLNESS 360 LLC
Entity Type:Organization
Organization Name:WELLNESS 360 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PA
Authorized Official - Prefix:
Authorized Official - First Name:ANANT
Authorized Official - Middle Name:
Authorized Official - Last Name:NISCHAL
Authorized Official - Suffix:
Authorized Official - Credentials:PA, PHD
Authorized Official - Phone:732-719-6864
Mailing Address - Street 1:200 PERRINE RD STE 230
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-2871
Mailing Address - Country:US
Mailing Address - Phone:732-707-3545
Mailing Address - Fax:732-707-3546
Practice Address - Street 1:145 ROUTE 34
Practice Address - Street 2:
Practice Address - City:MATAWAN
Practice Address - State:NJ
Practice Address - Zip Code:07747-2187
Practice Address - Country:US
Practice Address - Phone:732-719-6864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty