Healthcare Provider Details

I. General information

NPI: 1871027771
Provider Name (Legal Business Name): MW WELLNESS VI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 FIVE POINTS DR STE 169
ARLINGTON TX
76018-6057
US

IV. Provider business mailing address

509 S HYDE PARK AVE
TAMPA FL
33606-2266
US

V. Phone/Fax

Practice location:
  • Phone: 817-375-0537
  • Fax: 817-375-0537
Mailing address:
  • Phone: 813-228-6334
  • Fax: 813-228-6763

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: MR. EDWARD KALOUST
Title or Position: CEO
Credential:
Phone: 813-228-6334