Provider Demographics
NPI:1124631445
Name:MERIDIAN WELLNESS, PLLC
Entity type:Organization
Organization Name:MERIDIAN WELLNESS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORMAS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:517-618-9507
Mailing Address - Street 1:2422 JOLLY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3690
Mailing Address - Country:US
Mailing Address - Phone:517-618-9507
Mailing Address - Fax:
Practice Address - Street 1:2422 JOLLY RD STE 100
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3690
Practice Address - Country:US
Practice Address - Phone:517-618-9507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty