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General NPI Number Information
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NPI Number | 1194308494
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Entity Type | Organization
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Legal Business Name | MW WELLNESS VENTURES IV LLC
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Dates
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Enumeration Date | 05/04/2021
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Last Update Date | 05/04/2021
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Provider Practice Location Address
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Address Line | 370 FAUNCE CORNER RD
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City | DARTMOUTH
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State | MA
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Zip | 02747-1271
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Country | US
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Telephone | 813-228-6334
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Fax |
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Provider Business Mailing Address
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Address Line | 509 S HYDE PARK AVE
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City | TAMPA
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State | FL
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Zip | 33606-2266
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Country | US
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Telephone | 813-228-6334
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | STACEY HEALD
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Credential |
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Telephone | 813-228-6334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QB0002X
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Taxonomy Name | Obesity Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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