MEDICARE: UNITED MEDICAL WELLNESS COMPLEX, 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	405300000X	Prevention Professional
2	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1255045324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNITED MEDICAL WELLNESS COMPLEX, LLC

Provider Business Mailing Address
First Line	:	892 CENTRE ST
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-4509
Country	:	US
Telephone Number	:	769-567-1304
Fax Number	:	800-951-3880

Provider Business Practice Location Address
First Line	:	892 CENTRE ST
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-4509
Country	:	US
Telephone Number	:	769-251-2098
Fax Number	:	800-394-6187

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. KEVIN TAFT WRIGHT
Credential	:
Telephone Number	:	601-940-4195

Provider Enumeration Date	:	01/12/2023
Last Update Date	:	10/24/2023

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