=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447990155
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPPORTIVE WELLNESS CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2022
-----------------------------------------------------
Last Update Date | 03/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12322 WILD PINE DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77039-6423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-927-2513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10530 ENVOY ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77016-3232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-927-2513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ALIKE C ST JULES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-927-2513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------