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General NPI Number Information
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NPI Number | 1003099235
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Entity Type | Organization
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Legal Business Name | ADVANCED WELLNESS GROUP INC
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Dates
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Enumeration Date | 12/11/2007
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Last Update Date | 10/17/2012
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Provider Practice Location Address
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Address Line | 2705 E QUINLAN PKWY
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City | QUINLAN
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State | TX
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Zip | 75474-8688
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Country | US
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Telephone | 903-447-5470
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 789
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City | QUINLAN
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State | TX
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Zip | 75474-0014
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Country | US
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Telephone | 903-447-5470
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Fax |
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Authorized Official
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Title or Position | SUPERVISING PHYSICIAN
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Name | MR. KENNETH RONALD DORITY
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Credential | D.O.
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Telephone | 903-447-5470
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 170100000X
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Taxonomy Name | Ph.D. Medical Genetics
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License Number | K0722
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License Number State | TX
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