Healthcare Provider Details

I. General information

NPI: 1881070977
Provider Name (Legal Business Name): EXECUTIVE HEALTH AND WELLNESS OF TEXAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2015
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1643 LANCASTER DR STE 201
GRAPEVINE TX
76051-3593
US

IV. Provider business mailing address

1643 LANCASTER DR STE 201
GRAPEVINE TX
76051-3593
US

V. Phone/Fax

Practice location:
  • Phone: 817-328-0349
  • Fax: 972-852-9094
Mailing address:
  • Phone: 817-328-0349
  • Fax: 972-852-9094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK1232
License Number StateTX

VIII. Authorized Official

Name: DR. ALOK P KUSHWAHA
Title or Position: DIRECTOR
Credential: MD
Phone: 972-852-9140