Provider Demographics
NPI:1154587079
Name:WILDCATS WELLNESS CENTER
Entity type:Organization
Organization Name:WILDCATS WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LUANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-789-8814
Mailing Address - Street 1:225 E WATSON ST
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:MI
Mailing Address - Zip Code:49224-1194
Mailing Address - Country:US
Mailing Address - Phone:517-629-8464
Mailing Address - Fax:517-629-8466
Practice Address - Street 1:225 E WATSON ST
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:MI
Practice Address - Zip Code:49224-1194
Practice Address - Country:US
Practice Address - Phone:517-629-8464
Practice Address - Fax:517-629-8466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008706720OtherBCBSM
MI774911039Medicaid