Healthcare Provider Details

I. General information

NPI: 1295387595
Provider Name (Legal Business Name): WYTHE WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E MAIN ST STE B
WYTHEVILLE VA
24382-2300
US

IV. Provider business mailing address

PO BOX 65
WYTHEVILLE VA
24382-0065
US

V. Phone/Fax

Practice location:
  • Phone: 931-284-1362
  • Fax:
Mailing address:
  • Phone: 931-284-1362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JAMES WADE BOLTON
Title or Position: PRESIDENT AND CEO
Credential: DC, NP
Phone: 931-284-1362