MEDICARE: XAVIER 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1689254666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	XAVIER WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	4817 BRENTWOOD STAIR RD STE 105
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76103-1734
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4817 BRENTWOOD STAIR RD STE 105
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76103-1734
Country	:	US
Telephone Number	:	214-228-3072
Fax Number	:

Authorized Official
Title or Position	:	Q
Name	:	NICOLE WASHINGTON
Credential	:
Telephone Number	:	214-228-3072

Provider Enumeration Date	:	04/13/2021
Last Update Date	:	04/13/2021

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