Healthcare Provider Details

I. General information

NPI: 1376296152
Provider Name (Legal Business Name): PREVENTATIVE WELLNESS SOLUTIONS II, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3878 OXFORD STATION WAY
WINSTON SALEM NC
27103-1340
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 TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN KALOUST
Title or Position: MANAGER
Credential:
Phone: 813-228-6334