MEDICARE: NASHVILLE WELLNESS CLINIC & MEDI-SPA PA

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	31627	NC

General Provider Information

NPI Number	:	1508293192
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NASHVILLE WELLNESS CLINIC & MEDI-SPA PA

Provider Business Mailing Address
First Line	:	117 W CHURCH ST
Second Line	:
City	:	NASHVILLE
State	:	NC
Zip	:	27856-1327
Country	:	US
Telephone Number	:	252-459-5544
Fax Number	:	252-459-9300

Provider Business Practice Location Address
First Line	:	117 W CHURCH ST
Second Line	:
City	:	NASHVILLE
State	:	NC
Zip	:	27856-1327
Country	:	US
Telephone Number	:	252-459-5544
Fax Number	:	252-459-9300

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DONALD ALAN RIBEIRO
Credential	:	M.D.
Telephone Number	:	252-747-2089

Provider Enumeration Date	:	09/27/2013
Last Update Date	:	09/27/2013

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