Provider Demographics
NPI:1427540806
Name:ADVANCED WELLNESS
Entity Type:Organization
Organization Name:ADVANCED WELLNESS
Other - Org Name:ADVANCED WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:W
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-579-3931
Mailing Address - Street 1:212 OLD GRANDE BLVD STE A200
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4204
Mailing Address - Country:US
Mailing Address - Phone:214-327-3186
Mailing Address - Fax:
Practice Address - Street 1:5605 OLD BULLARD RD STE B
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703
Practice Address - Country:US
Practice Address - Phone:903-630-5595
Practice Address - Fax:903-630-5599
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVWELLNESS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-01
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty