Provider Demographics
NPI:1356664676
Name:DAN WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:DAN WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAKYUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:YUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-455-5464
Mailing Address - Street 1:2211 N FRY RD
Mailing Address - Street 2:SUITE # I
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-7225
Mailing Address - Country:US
Mailing Address - Phone:832-455-5464
Mailing Address - Fax:281-955-9695
Practice Address - Street 1:2211 N FRY RD
Practice Address - Street 2:SUITE # I
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-7225
Practice Address - Country:US
Practice Address - Phone:832-455-5464
Practice Address - Fax:281-955-9695
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATIVE CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01178261QH0100X
TX619494261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ60885Medicare UPIN