Healthcare Provider Details

I. General information

NPI: 1356723563
Provider Name (Legal Business Name): MW WELLNESS XVII, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4407 OLD SHELL RD STE D
MOBILE AL
36608-1924
US

IV. Provider business mailing address

509 S HYDE PARK AVE
TAMPA FL
33606-2266
US

V. Phone/Fax

Practice location:
  • Phone: 813-228-6334
  • Fax:
Mailing address:
  • Phone: 813-228-6334
  • Fax: 813-228-6763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberBL007515-01-2015
License Number StateSC

VIII. Authorized Official

Name: JODI DESPOY
Title or Position: MANAGER
Credential:
Phone: 813-228-6334