Healthcare Provider Details

I. General information

NPI: 1023511763
Provider Name (Legal Business Name): MW WELLNESS VENTURES I, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 ORCHARD VIEW DR STE 2
LONDONDERRY NH
03053-3376
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

VIII. Authorized Official

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