Provider Demographics
NPI:1215594577
Name:GRAPEVINE TOTAL WELLNESS PLLC
Entity Type:Organization
Organization Name:GRAPEVINE TOTAL WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:800-246-5698
Mailing Address - Street 1:5000 ELDORADO PKWY STE 150-153
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-8695
Mailing Address - Country:US
Mailing Address - Phone:800-246-5698
Mailing Address - Fax:
Practice Address - Street 1:1000 W ST HWY 114
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3987
Practice Address - Country:US
Practice Address - Phone:800-246-5698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MODERN MALE T-CLINIC, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty