Provider Demographics
NPI:1598294514
Name:WELLNESS WITHIN
Entity Type:Organization
Organization Name:WELLNESS WITHIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN & OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:228-206-6843
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-0253
Mailing Address - Country:US
Mailing Address - Phone:228-206-6843
Mailing Address - Fax:228-357-9366
Practice Address - Street 1:2202 25TH AVE STE B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-4520
Practice Address - Country:US
Practice Address - Phone:228-206-6843
Practice Address - Fax:228-206-6843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23342207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05351053Medicaid