Healthcare Provider Details

I. General information

NPI: 1497024905
Provider Name (Legal Business Name): MENS WELLNESS CENTER ONE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3724 JEFFERSON ST STE 112
AUSTIN TX
78731-6225
US

IV. Provider business mailing address

3724 JEFFERSON ST STE 112
AUSTIN TX
78731-6225
US

V. Phone/Fax

Practice location:
  • Phone: 512-454-9700
  • Fax: 512-407-9511
Mailing address:
  • Phone: 512-454-9700
  • Fax: 512-407-9511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberE8227
License Number StateTX

VIII. Authorized Official

Name: DR. DAVID LEE WEILER
Title or Position: MEDICAL DOCTOR/DIRECTOR
Credential: M.D.
Phone: 512-454-9700