Provider Demographics
NPI:1629824743
Name:VIRGINIA PARK WELLNESS CENTER LLC
Entity type:Organization
Organization Name:VIRGINIA PARK WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EPHRAIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ONWUEGBUCHU
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-525-6566
Mailing Address - Street 1:11748 HEATHERWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4188
Mailing Address - Country:US
Mailing Address - Phone:313-525-6566
Mailing Address - Fax:
Practice Address - Street 1:8500 14TH ST STE 101
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-2574
Practice Address - Country:US
Practice Address - Phone:313-894-3950
Practice Address - Fax:313-894-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-29
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty