Provider Demographics
NPI:1699268672
Name:WELLNESSCONNECT HEALTHCARE AND PREVENTIVE MEDICINE, LLC
Entity type:Organization
Organization Name:WELLNESSCONNECT HEALTHCARE AND PREVENTIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:256-907-2493
Mailing Address - Street 1:2011 GALLATIN ST SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-4510
Mailing Address - Country:US
Mailing Address - Phone:256-907-2493
Mailing Address - Fax:256-907-1726
Practice Address - Street 1:2011 GALLATIN ST SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4510
Practice Address - Country:US
Practice Address - Phone:256-907-2493
Practice Address - Fax:256-281-8134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00013209207Q00000X
ALMD132092081P2900X, 2083B0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1285741553OtherNPI
AL1760437313OtherNPI
AL1912186032OtherNPI