MEDICARE: GOOD HEALTH PEDIATRICS & WELLNESS CLINIC, LLC

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	208000000X	Pediatrics Physician	J6191	TX

General Provider Information

NPI Number	:	1225360647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOOD HEALTH PEDIATRICS & WELLNESS CLINIC, LLC

Provider Business Mailing Address
First Line	:	303 FM 517 RD E
Second Line	:
City	:	DICKINSON
State	:	TX
Zip	:	77539-8630
Country	:	US
Telephone Number	:	281-534-9255
Fax Number	:	281-534-9322

Provider Business Practice Location Address
First Line	:	303 FM 517 RD E
Second Line	:
City	:	DICKINSON
State	:	TX
Zip	:	77539-8630
Country	:	US
Telephone Number	:	281-534-9255
Fax Number	:	281-534-9322

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LINDA RENESE NEELY-SHELMIRE
Credential	:	M.D.
Telephone Number	:	281-534-9355

Provider Enumeration Date	:	02/10/2010
Last Update Date	:	07/19/2011

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