Provider Demographics
NPI:1104256221
Name:WELLNESS RESIDENTIAL SERVICES
Entity type:Organization
Organization Name:WELLNESS RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:IDORENYIN
Authorized Official - Middle Name:UDO
Authorized Official - Last Name:FRED
Authorized Official - Suffix:
Authorized Official - Credentials:STUDENT
Authorized Official - Phone:513-969-4160
Mailing Address - Street 1:260 NORTHLAND BLVD STE 216
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3651
Mailing Address - Country:US
Mailing Address - Phone:513-969-4160
Mailing Address - Fax:513-737-0018
Practice Address - Street 1:260 NORTHLAND BLVD STE 216
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-3651
Practice Address - Country:US
Practice Address - Phone:513-969-4160
Practice Address - Fax:513-737-0018
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLNESS RESIDENTIAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-27
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH364SH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome HealthGroup - Single Specialty