Provider Demographics
NPI:1689149734
Name:NOURISHED MEDSPA AND WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:NOURISHED MEDSPA AND WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-818-3467
Mailing Address - Street 1:1043 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-5192
Mailing Address - Country:US
Mailing Address - Phone:903-818-3467
Mailing Address - Fax:
Practice Address - Street 1:1043 RIDGEVIEW DR
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-5192
Practice Address - Country:US
Practice Address - Phone:903-818-3467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty