Provider Demographics
NPI:1770857443
Name:XCEPTIONAL HEALTH & WELLNESS, PLLC.
Entity Type:Organization
Organization Name:XCEPTIONAL HEALTH & WELLNESS, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:F
Authorized Official - Last Name:PETRIDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-510-6507
Mailing Address - Street 1:5779 GETWELL RD
Mailing Address - Street 2:BLDG. D, SUITE 3
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6347
Mailing Address - Country:US
Mailing Address - Phone:662-510-6507
Mailing Address - Fax:662-510-6508
Practice Address - Street 1:5779 GETWELL RD
Practice Address - Street 2:BLDG. D, SUITE 3
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-6347
Practice Address - Country:US
Practice Address - Phone:662-510-6507
Practice Address - Fax:662-510-6508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty