Healthcare Provider Details

I. General information

NPI: 1518405737
Provider Name (Legal Business Name): MW WELLNESS IV, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W HWY 6 SUITE 108
WACO TX
76710-7544
US

IV. Provider business mailing address

611 W HWY 6 SUITE 108
WACO TX
76710-7544
US

V. Phone/Fax

Practice location:
  • Phone: 254-741-8686
  • Fax: 254-741-8687
Mailing address:
  • Phone: 254-741-8686
  • Fax: 254-741-8687

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: WENDIE NONCLERC
Title or Position: DIRECTOR OF INSURANCE DEVELOPMENT
Credential:
Phone: 813-228-6334