Healthcare Provider Details

I. General information

NPI: 1093269334
Provider Name (Legal Business Name): YOUR WELLNESS CHOICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1143 CULLY RD
CORDOVA TN
38018-8502
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 901-672-6410
  • Fax: 901-752-8843
Mailing address:
  • Phone: 317-621-7562
  • Fax: 317-806-1157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IMELDA WILLIAMS
Title or Position: OWNER
Credential:
Phone: 901-672-6410