Provider Demographics
NPI:1942740188
Name:PERSONALIZED WELLNESS
Entity Type:Organization
Organization Name:PERSONALIZED WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-955-1804
Mailing Address - Street 1:573 HIGHWAY 51 STE D
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2605
Mailing Address - Country:US
Mailing Address - Phone:601-955-1804
Mailing Address - Fax:
Practice Address - Street 1:573 HIGHWAY 51 STE D
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2605
Practice Address - Country:US
Practice Address - Phone:601-955-1804
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13234208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty