Provider Demographics
NPI:1700248416
Name:CONNECTICUT AVE HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:CONNECTICUT AVE HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:202-966-9280
Mailing Address - Street 1:5530 WISCONSIN AVE STE 1248
Mailing Address - Street 2:
Mailing Address - City:CHEVY CHASE
Mailing Address - State:MD
Mailing Address - Zip Code:20815-4301
Mailing Address - Country:US
Mailing Address - Phone:202-966-9280
Mailing Address - Fax:202-966-9380
Practice Address - Street 1:5530 WISCONSIN AVE STE 1248
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4301
Practice Address - Country:US
Practice Address - Phone:202-966-9280
Practice Address - Fax:202-966-9380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG00791Medicare PIN