=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053287771
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANDEWELL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2025
-----------------------------------------------------
Last Update Date | 10/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 E JOHNSON ST
-----------------------------------------------------
City | TATUM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75691-1914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-265-2710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13460 STATE HIGHWAY 43 E
-----------------------------------------------------
City | TATUM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75691-4763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-265-2710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGISTERED DIETITIAN
-----------------------------------------------------
Name | MRS. TAMMY LYNN TUBBLEVILLE
-----------------------------------------------------
Credential | RDN
-----------------------------------------------------
Telephone | 903-265-2710
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------