Provider Demographics
NPI:1952789513
Name:ADVANCED CENTER FOR WELLNESS, LLC
Entity Type:Organization
Organization Name:ADVANCED CENTER FOR WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:956-727-2629
Mailing Address - Street 1:6801 MCPHERSON RD STE 213
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-6443
Mailing Address - Country:US
Mailing Address - Phone:956-727-2629
Mailing Address - Fax:956-727-4629
Practice Address - Street 1:6801 MCPHERSON RD STE 213
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-6443
Practice Address - Country:US
Practice Address - Phone:956-727-2629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty