Healthcare Provider Details

I. General information

NPI: 1609297902
Provider Name (Legal Business Name): WELLNESS MED CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2014
Last Update Date: 01/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 S IH 35 STE 250A
AUSTIN TX
78745-3344
US

IV. Provider business mailing address

5510 S IH 35 STE 250A
AUSTIN TX
78745-3344
US

V. Phone/Fax

Practice location:
  • Phone: 512-301-1166
  • Fax:
Mailing address:
  • Phone: 512-301-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH3680
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03274
License Number StateTX

VIII. Authorized Official

Name: MRS. CANDICE AGUIRRE
Title or Position: COO
Credential:
Phone: 512-301-1166