Provider Demographics
NPI:1003611187
Name:REVERSE TIME WELLNESS INC
Entity type:Organization
Organization Name:REVERSE TIME WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NEISHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:203-274-7426
Mailing Address - Street 1:1086 LONG RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06903-4404
Mailing Address - Country:US
Mailing Address - Phone:203-274-7426
Mailing Address - Fax:203-274-7426
Practice Address - Street 1:1086 LONG RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06903-4404
Practice Address - Country:US
Practice Address - Phone:203-274-7426
Practice Address - Fax:203-274-7426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-13
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty