MEDICARE: WELLNESS CLINIC, P.A.

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	207Q00000X	Family Medicine Physician	K2264	TX

General Provider Information

NPI Number	:	1417107426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESS CLINIC, P.A.

Provider Business Mailing Address
First Line	:	1515 N COCKRELL HILL RD
Second Line	:	STE 113
City	:	DALLAS
State	:	TX
Zip	:	75211-1315
Country	:	US
Telephone Number	:	214-339-9090
Fax Number	:	214-339-9023

Provider Business Practice Location Address
First Line	:	1515 N COCKRELL HILL RD
Second Line	:	STE 113
City	:	DALLAS
State	:	TX
Zip	:	75211-1315
Country	:	US
Telephone Number	:	214-339-9090
Fax Number	:	214-339-9023

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JUAN FRANCISCO QUIROZ
Credential	:	M.D.
Telephone Number	:	214-339-9090

Provider Enumeration Date	:	09/25/2008
Last Update Date	:	09/25/2008

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