Healthcare Provider Details

I. General information

NPI: 1174251227
Provider Name (Legal Business Name): EIR WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 TUSCANNY ST
BRANDON FL
33511-6151
US

IV. Provider business mailing address

802 TUSCANNY ST
BRANDON FL
33511-6151
US

V. Phone/Fax

Practice location:
  • Phone: 863-825-6121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARY JOYCE GAN
Title or Position: MD
Credential: MD
Phone: 863-825-6121