Provider Demographics
NPI:1073913588
Name:ANBAP WELLNESS LLC
Entity Type:Organization
Organization Name:ANBAP WELLNESS LLC
Other - Org Name:OPTIMUM MEDICAL WEIGHT CONTROL AND FAMILY WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:409-221-8294
Mailing Address - Street 1:560 LARRY WARD
Mailing Address - Street 2:
Mailing Address - City:BRIDGE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77611-2432
Mailing Address - Country:US
Mailing Address - Phone:409-221-8294
Mailing Address - Fax:
Practice Address - Street 1:1001 NEDERLAND AVE
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-2832
Practice Address - Country:US
Practice Address - Phone:409-221-8294
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANBAP WLLNESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-03
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX758246364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty