Provider Demographics
NPI:1356723563
Name:MW WELLNESS XVII, LLC
Entity type:Organization
Organization Name:MW WELLNESS XVII, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:DESPOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-228-6334
Mailing Address - Street 1:509 S HYDE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2266
Mailing Address - Country:US
Mailing Address - Phone:813-228-6334
Mailing Address - Fax:813-228-6763
Practice Address - Street 1:4407 OLD SHELL RD STE D
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1924
Practice Address - Country:US
Practice Address - Phone:813-228-6334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCBL007515-01-2015207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty