Provider Demographics
NPI:1184621120
Name:NEW HORIZONS WELLNESS CENTER
Entity type:Organization
Organization Name:NEW HORIZONS WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:334-347-4343
Mailing Address - Street 1:300 N EDWARDS ST
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2508
Mailing Address - Country:US
Mailing Address - Phone:334-347-4343
Mailing Address - Fax:334-393-9611
Practice Address - Street 1:1018 RUCKER BLVD STE A
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-3688
Practice Address - Country:US
Practice Address - Phone:334-347-4343
Practice Address - Fax:334-393-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO463261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529918990Medicaid