=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699493676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TELEHEALTH WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2022
-----------------------------------------------------
Last Update Date | 08/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 837 N MAIN ST SPC 118
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77657-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-877-1773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 837 N MAIN ST SPC 118
-----------------------------------------------------
City | LUMBERTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77657-1018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-877-1773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JEFFREY J GUILLORY JR.
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 409-877-1773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------