=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790971448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WATSON'S WELLNESS CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2007
-----------------------------------------------------
Last Update Date | 05/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3525 FM 1960 RD E
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77338-5317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-540-1018
-----------------------------------------------------
Fax | 281-540-7581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3525 FM 1960 RD E
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77338-5317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-540-1018
-----------------------------------------------------
Fax | 281-540-7581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARVIN R WATSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 281-540-1018
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC6128
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------