Healthcare Provider Details

I. General information

NPI: 1902086879
Provider Name (Legal Business Name): WELLSPINE,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12655 N CENTRAL EXPY STE 650
DALLAS TX
75243-1770
US

IV. Provider business mailing address

8215 WESTCHESTER DR SUITE 320
DALLAS TX
75225-6103
US

V. Phone/Fax

Practice location:
  • Phone: 214-819-9600
  • Fax: 214-819-9601
Mailing address:
  • Phone: 214-819-9600
  • Fax: 214-819-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberJ6872
License Number StateTX

VIII. Authorized Official

Name: AMANDA THOMPSON WIER
Title or Position: ADMINISTRATOR
Credential:
Phone: 214-819-9600