Healthcare Provider Details

I. General information

NPI: 1942971353
Provider Name (Legal Business Name): ALICE HEALTH & WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 E SAN PATRICIO AVE
MATHIS TX
78368-2402
US

IV. Provider business mailing address

PO BOX 61160
CORPUS CHRISTI TX
78466-1160
US

V. Phone/Fax

Practice location:
  • Phone: 361-453-4470
  • Fax: 800-621-5209
Mailing address:
  • Phone: 361-453-4470
  • Fax: 361-415-2224

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: PETRA DELEON
Title or Position: OWNER
Credential: FNP
Phone: 210-980-0885