Provider Demographics
NPI:1891076998
Name:WELLNESS CENTRE LLC
Entity Type:Organization
Organization Name:WELLNESS CENTRE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENITO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-514-2614
Mailing Address - Street 1:15945 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1147
Mailing Address - Country:US
Mailing Address - Phone:248-514-2614
Mailing Address - Fax:
Practice Address - Street 1:15945 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1147
Practice Address - Country:US
Practice Address - Phone:248-514-2614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty