=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780490524
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ON THE GO WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2024
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3935 BANKS LANDING CT
-----------------------------------------------------
City | FULSHEAR
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77441-4553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-665-7258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3935 BANKS LANDING CT
-----------------------------------------------------
City | FULSHEAR
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77441-4553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARITZA ROMERO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-995-6073
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------