MEDICARE: ROCKWOOD WELLNESS CLINIC 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	:	1750275947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKWOOD WELLNESS CLINIC LLC

Provider Business Mailing Address
First Line	:	1217 GRAND AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76164-9041
Country	:	US
Telephone Number	:	817-625-7733
Fax Number	:

Provider Business Practice Location Address
First Line	:	1217 GRAND AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76164-9041
Country	:	US
Telephone Number	:	817-625-7733
Fax Number	:

Authorized Official
Title or Position	:	BILLING MGR
Name	:	JANIS MCDANIEL
Credential	:
Telephone Number	:	512-253-7794

Provider Enumeration Date	:	06/04/2025
Last Update Date	:	06/04/2025

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Directions to “ROCKWOOD WELLNESS CLINIC LLC ” Practice Location

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