Provider Demographics
NPI:1942971353
Name:ALICE HEALTH & WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:ALICE HEALTH & WELLNESS CLINIC LLC
Other - Org Name:MATHIS HEALTH & WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELEON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:210-980-0885
Mailing Address - Street 1:PO BOX 61160
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-1160
Mailing Address - Country:US
Mailing Address - Phone:361-453-4470
Mailing Address - Fax:361-415-2224
Practice Address - Street 1:1205 E SAN PATRICIO AVE
Practice Address - Street 2:
Practice Address - City:MATHIS
Practice Address - State:TX
Practice Address - Zip Code:78368-2402
Practice Address - Country:US
Practice Address - Phone:361-453-4470
Practice Address - Fax:800-621-5209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-24
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty