MEDICARE: COSMEDIC WELLNESS CENTERS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician

General Provider Information

NPI Number	:	1053883405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COSMEDIC WELLNESS CENTERS, INC

Provider Business Mailing Address
First Line	:	1030 E HWY 377 STE 114
Second Line	:
City	:	GRANBURY
State	:	TX
Zip	:	76048-1457
Country	:	US
Telephone Number	:	817-579-2660
Fax Number	:	877-456-6014

Provider Business Practice Location Address
First Line	:	1030 E HWY 377 STE 114
Second Line	:
City	:	GRANBURY
State	:	TX
Zip	:	76048-1457
Country	:	US
Telephone Number	:	817-579-2660
Fax Number	:	877-465-6014

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	KELLY CHRISTINE KREPINEVICH
Credential	:
Telephone Number	:	817-579-2660

Provider Enumeration Date	:	12/26/2018
Last Update Date	:	03/19/2024

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