Provider Demographics
NPI:1003099235
Name:ADVANCED WELLNESS GROUP INC
Entity Type:Organization
Organization Name:ADVANCED WELLNESS GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:DORITY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:903-447-5470
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:QUINLAN
Mailing Address - State:TX
Mailing Address - Zip Code:75474-0014
Mailing Address - Country:US
Mailing Address - Phone:903-447-5470
Mailing Address - Fax:
Practice Address - Street 1:2705 E QUINLAN PKWY
Practice Address - Street 2:
Practice Address - City:QUINLAN
Practice Address - State:TX
Practice Address - Zip Code:75474-8688
Practice Address - Country:US
Practice Address - Phone:903-447-5470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0722170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Single Specialty