Provider Demographics
NPI:1073163549
Name:EAST TEXAS HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:EAST TEXAS HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BARBOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:903-320-3200
Mailing Address - Street 1:PO BOX 45
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-0045
Mailing Address - Country:US
Mailing Address - Phone:903-320-3200
Mailing Address - Fax:903-471-8655
Practice Address - Street 1:1600 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-6852
Practice Address - Country:US
Practice Address - Phone:903-320-3200
Practice Address - Fax:903-471-8655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TEXAS PRECISION MEDICINE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty