Healthcare Provider Details

I. General information

NPI: 1639695935
Provider Name (Legal Business Name): MW WELLNESS VIII, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 HAZARD AVE STE 2
ENFIELD CT
06082
US

IV. Provider business mailing address

155 HAZARD AVE STE 2
ENFIELD CT
06082-4586
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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