Provider Demographics
NPI:1255381620
Name:NORTHEAST WELLNESS CONNECTION INC
Entity type:Organization
Organization Name:NORTHEAST WELLNESS CONNECTION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMENIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:CERRUTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-676-4070
Mailing Address - Street 1:2869 HOLM AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19152
Mailing Address - Country:US
Mailing Address - Phone:215-676-4070
Mailing Address - Fax:215-676-4071
Practice Address - Street 1:2869 HOLM AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19152
Practice Address - Country:US
Practice Address - Phone:215-676-4070
Practice Address - Fax:215-676-4071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008976L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA046596Medicare PIN