Provider Demographics
NPI:1750046363
Name:WELLNESSCLINIC ON WHEELS
Entity Type:Organization
Organization Name:WELLNESSCLINIC ON WHEELS
Other - Org Name:AFTERHOURS LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EL AGATHE
Authorized Official - Middle Name:ASOPO
Authorized Official - Last Name:TEMBENG
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:202-834-7722
Mailing Address - Street 1:1747 FORT SMITH BLVD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-3728
Mailing Address - Country:US
Mailing Address - Phone:202-834-7722
Mailing Address - Fax:
Practice Address - Street 1:1747 FORT SMITH BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-3728
Practice Address - Country:US
Practice Address - Phone:202-834-7722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-08
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care