=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720401268
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CENTER FOR RENEWED HEALTH & WELLNESS, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2014
-----------------------------------------------------
Last Update Date | 02/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3625 N HALL ST SUITE 600
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75219-5106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-763-1576
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 118383 ATTENTION: MIKE WALDEN
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75011-8383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-763-1576
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | NIKKI A WALDEN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 214-763-2992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | L8999
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------