Provider Demographics
NPI:1922479369
Name:WELLNESS LOCKER
Entity Type:Organization
Organization Name:WELLNESS LOCKER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:OLIVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-564-2323
Mailing Address - Street 1:P.O. BOX 348
Mailing Address - Street 2:
Mailing Address - City:WAUREGAN
Mailing Address - State:CT
Mailing Address - Zip Code:06387-0348
Mailing Address - Country:US
Mailing Address - Phone:860-481-2950
Mailing Address - Fax:860-412-9138
Practice Address - Street 1:19 S. WALNUT ST, STE D
Practice Address - Street 2:
Practice Address - City:WAUREGAN
Practice Address - State:CT
Practice Address - Zip Code:06387-8700
Practice Address - Country:US
Practice Address - Phone:860-481-2950
Practice Address - Fax:860-412-9138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT53961207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008062229Medicaid