Provider Demographics
NPI:1396259297
Name:R2 WELLNESS MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:R2 WELLNESS MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN EEDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-571-6505
Mailing Address - Street 1:451 WESTPARK WAY STE 5
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-3703
Mailing Address - Country:US
Mailing Address - Phone:817-571-6505
Mailing Address - Fax:
Practice Address - Street 1:451 WESTPARK WAY STE 1
Practice Address - Street 2:
Practice Address - City:EULESS
Practice Address - State:TX
Practice Address - Zip Code:76040-3994
Practice Address - Country:US
Practice Address - Phone:817-571-6505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0723261QH0100X, 2083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty