Provider Demographics
NPI:1831296102
Name:THE WELLNESS PLACE PC
Entity Type:Organization
Organization Name:THE WELLNESS PLACE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARMELLA
Authorized Official - Middle Name:N
Authorized Official - Last Name:IMIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:402-332-4559
Mailing Address - Street 1:818 VILLAGE SQ.
Mailing Address - Street 2:P.O. BOX 527
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-7914
Mailing Address - Country:US
Mailing Address - Phone:402-332-4559
Mailing Address - Fax:402-332-4598
Practice Address - Street 1:818 VILLAGE SQ.
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-7914
Practice Address - Country:US
Practice Address - Phone:402-332-4559
Practice Address - Fax:402-332-4598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========13Medicaid
NE=========13Medicaid