Healthcare Provider Details

I. General information

NPI: 1780344515
Provider Name (Legal Business Name): MW WELLNESS XV LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 FEDERAL RD STE 100
BROOKFIELD CT
06804-2539
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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