1396259297 NPI number — R2 WELLNESS MEDICAL GROUP PLLC

Table of content: (NPI 1396259297)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396259297 NPI number — R2 WELLNESS MEDICAL GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
R2 WELLNESS MEDICAL GROUP PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396259297
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
451 WESTPARK WAY STE 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EULESS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76040-3703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-571-6505
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 WESTPARK WAY STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EULESS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76040-3994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-571-6505
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2017

Additional Information

Authorized Official

Authorized Official Last Name:
VAN EEDEN
Authorized Official First Name:
JOHNETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
817-571-6505

Provider Taxonomy Codes

  • Taxonomy code: 2083P0500X , with the licence number:  G0723 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QH0100X , with the licence number: G0723 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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