MEDICARE: WORKSITE WELLNESS, INC.

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	H0913	TX
2	163WX0106X	Occupational Health Registered Nurse	576843	TX

General Provider Information

NPI Number	:	1851673248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WORKSITE WELLNESS, INC.

Provider Business Mailing Address
First Line	:	3524 SERENDIPITY HILLS TRL
Second Line	:
City	:	CORINTH
State	:	TX
Zip	:	76210-3601
Country	:	US
Telephone Number	:	940-391-6489
Fax Number	:	940-497-2192

Provider Business Practice Location Address
First Line	:	3524 SERENDIPITY HILLS TRL
Second Line	:
City	:	CORINTH
State	:	TX
Zip	:	76210-3601
Country	:	US
Telephone Number	:	940-391-6489
Fax Number	:	940-497-2192

Authorized Official
Title or Position	:	CONSULTANT/OWNER
Name	:	GABRIELLE DORAIS
Credential	:
Telephone Number	:	940-391-6489

Provider Enumeration Date	:	09/13/2011
Last Update Date	:	09/13/2011

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Directions to “WORKSITE WELLNESS, INC. ” Practice Location

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