Provider Demographics
NPI:1669833208
Name:HOME TEAM HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:HOME TEAM HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:210-846-4979
Mailing Address - Street 1:1571 THOUSAND OAKS DR STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-2689
Mailing Address - Country:US
Mailing Address - Phone:210-846-4979
Mailing Address - Fax:186-626-8562
Practice Address - Street 1:1280 TRACY DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78260-5702
Practice Address - Country:US
Practice Address - Phone:210-846-4979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX680616363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty