Provider Demographics
NPI:1679523278
Name:NEW IMAGE BODY AND WELLNESS CLINIC, PC
Entity type:Organization
Organization Name:NEW IMAGE BODY AND WELLNESS CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KACEL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:248-682-6627
Mailing Address - Street 1:1396 SCOTT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-1578
Mailing Address - Country:US
Mailing Address - Phone:248-682-6627
Mailing Address - Fax:
Practice Address - Street 1:2590 ELIZABETH LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3314
Practice Address - Country:US
Practice Address - Phone:248-682-6627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI06914E261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ30867Medicare UPIN