MEDICARE: ROCKPORT WELLNESS CENTER, 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	207Q00000X	Family Medicine Physician	L1379	TX

General Provider Information

NPI Number	:	1417398876
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROCKPORT WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	PO BOX 12609
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-4017
Country	:	US
Telephone Number	:	361-450-0347
Fax Number	:	361-450-0484

Provider Business Practice Location Address
First Line	:	1521 W MARKET ST
Second Line	:	SUITE D
City	:	ROCKPORT
State	:	TX
Zip	:	78382-6218
Country	:	US
Telephone Number	:	361-450-0347
Fax Number	:	361-450-0484

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	KIMBERLY S. MARONEY
Credential	:	MD
Telephone Number	:	361-450-0347

Provider Enumeration Date	:	07/15/2013
Last Update Date	:	11/25/2013

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Directions to “ROCKPORT WELLNESS CENTER, LLC ” Practice Location

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