MEDICARE: WENDYS SENIORCARE CONSULTING, 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	171400000X	Health & Wellness Coach
2	363LG0600X	Gerontology Nurse Practitioner

General Provider Information

NPI Number	:	1861074700
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WENDYS SENIORCARE CONSULTING, LLC

Provider Business Mailing Address
First Line	:	13122 QUINLAN RNCH
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-3421
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13122 QUINLAN RNCH
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-3421
Country	:	US
Telephone Number	:	210-837-4196
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	WENDY VAN DYKE
Credential	:	NP
Telephone Number	:	210-837-4196

Provider Enumeration Date	:	04/21/2021
Last Update Date	:	05/11/2021

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