Provider Demographics
NPI:1811371388
Name:VIVIFY WELLNESS CENTER
Entity Type:Organization
Organization Name:VIVIFY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENECHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:ANAMEKWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-941-8484
Mailing Address - Street 1:PO BOX 1119
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-1119
Mailing Address - Country:US
Mailing Address - Phone:972-941-8484
Mailing Address - Fax:972-941-8480
Practice Address - Street 1:500 S WESTGATE WAY
Practice Address - Street 2:SUITE #300
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-5308
Practice Address - Country:US
Practice Address - Phone:972-941-8484
Practice Address - Fax:972-941-8480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207R00000X, 207RA0000X, 207RG0300X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty