Provider Demographics
NPI:1336593128
Name:SOUTH TEXAS WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:SOUTH TEXAS WELLNESS CENTER LLC
Other - Org Name:MEDI WEIGHTLOSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:ENRIQUE
Authorized Official - Last Name:ROSAS-RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-467-5920
Mailing Address - Street 1:1108 S 1ST 1/2 ST
Mailing Address - Street 2:NONE
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-1149
Mailing Address - Country:US
Mailing Address - Phone:956-381-2747
Mailing Address - Fax:956-928-9464
Practice Address - Street 1:1700 W DOVE AVE UNIT 80
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-4462
Practice Address - Country:US
Practice Address - Phone:956-467-5920
Practice Address - Fax:956-928-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
TXE1133207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty