MEDICARE: EASTSIDE CLINIC & WELLNESS CENTER PLLC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1811300163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTSIDE CLINIC & WELLNESS CENTER PLLC

Provider Business Mailing Address
First Line	:	2400 WHELESS LN
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78723-2016
Country	:	US
Telephone Number	:	512-363-5725
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 WHELESS LN
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78723-2016
Country	:	US
Telephone Number	:	512-363-5725
Fax Number	:	512-363-5901

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ABRAHAM LEIJA
Credential	:
Telephone Number	:	512-574-0228

Provider Enumeration Date	:	06/04/2014
Last Update Date	:	06/22/2023

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