Provider Demographics
NPI:1003514597
Name:OLD CORNER WELLNESS INC
Entity type:Organization
Organization Name:OLD CORNER WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:NIEMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-826-5122
Mailing Address - Street 1:200 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST
Mailing Address - State:TX
Mailing Address - Zip Code:76691-1207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST
Practice Address - State:TX
Practice Address - Zip Code:76691-1207
Practice Address - Country:US
Practice Address - Phone:254-826-5122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-23
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center