MEDICARE: ROCKY CREEK INTEGRATED MEDICAL & WELLNESS CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1255033015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKY CREEK INTEGRATED MEDICAL & WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	3281 ROCKY CREEK DR STE 200
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4750
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3281 ROCKY CREEK DR STE 200
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-4750
Country	:	US
Telephone Number	:	281-607-5551
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SCOTT WADMAN
Credential	:
Telephone Number	:	281-607-5551

Provider Enumeration Date	:	03/17/2023
Last Update Date	:	03/17/2023

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