Provider Demographics
NPI:1700433653
Name:GLC WELLNESS CENTER TEXAS LLC
Entity Type:Organization
Organization Name:GLC WELLNESS CENTER TEXAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANTE
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-587-8106
Mailing Address - Street 1:777 E WHEATLAND RD STE 106
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-4918
Mailing Address - Country:US
Mailing Address - Phone:702-587-8106
Mailing Address - Fax:972-685-5108
Practice Address - Street 1:777 E WHEATLAND RD STE 106
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4918
Practice Address - Country:US
Practice Address - Phone:702-587-8106
Practice Address - Fax:972-685-5108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-23
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX405039501Medicaid
TX455039503Medicaid
TX405039504Medicaid
TX405039502Medicaid