Provider Demographics
NPI:1386023828
Name:MEDICAL WELLNESS LLC
Entity type:Organization
Organization Name:MEDICAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:JESKE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:203-948-1300
Mailing Address - Street 1:503 WOLCOTT RD
Mailing Address - Street 2:#3
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-2673
Mailing Address - Country:US
Mailing Address - Phone:203-948-1300
Mailing Address - Fax:888-372-6480
Practice Address - Street 1:503 WOLCOTT RD
Practice Address - Street 2:#3
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-2673
Practice Address - Country:US
Practice Address - Phone:203-948-1300
Practice Address - Fax:888-372-6480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12.004592261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care