Provider Demographics
NPI:1811098866
Name:ENHANCED WELLNESS, PLLC
Entity type:Organization
Organization Name:ENHANCED WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:FELICE
Authorized Official - Last Name:BLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:RHIA
Authorized Official - Phone:601-364-1132
Mailing Address - Street 1:1855 LAKELAND DRIVE
Mailing Address - Street 2:STE M20
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-364-1132
Mailing Address - Fax:601-364-1134
Practice Address - Street 1:1855 LAKELAND DRIVE
Practice Address - Street 2:STE M20
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-364-1132
Practice Address - Fax:601-364-1134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2013-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03582Medicare PIN