Provider Demographics
NPI:1457632440
Name:COMMUNITY WELLNESS CLINIC, LLP
Entity Type:Organization
Organization Name:COMMUNITY WELLNESS CLINIC, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:N/A
Authorized Official - Prefix:
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-760-2784
Mailing Address - Street 1:201 ENTERPRISE ROW STE 12
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-4448
Mailing Address - Country:US
Mailing Address - Phone:936-760-2784
Mailing Address - Fax:936-760-1950
Practice Address - Street 1:201 ENTERPRISE ROW
Practice Address - Street 2:SUITE 12
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-4448
Practice Address - Country:US
Practice Address - Phone:936-760-2784
Practice Address - Fax:936-760-1950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-02
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4636207Q00000X, 207Q00000X
TXBZ3718105261QP0905X
TX261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018986204Medicaid
TX018986203Medicaid