1093028755 NPI number — SCIENCE OF WELLNESS

Table of content: (NPI 1093028755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093028755 NPI number — SCIENCE OF WELLNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCIENCE OF WELLNESS
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:
6
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:
1093028755
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8811 TEEL PKWY STE 180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRISCO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75034-4427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-704-1890
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8811 TEEL PKWY
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
FRISCO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-704-1890
Provider Business Practice Location Address Fax Number:
972-704-1891
Provider Enumeration Date:
07/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GATEWOOD
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
ADAM
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
972-704-1890

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  11587 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 111N00000X , with the licence number: 10591 , 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)

  • Identifier: 0044TY . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8CN790 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8CN791 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1093028755 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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