Provider Demographics
NPI:1902158009
Name:SHARE WELLNESS MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:SHARE WELLNESS MEDICAL CLINIC PLLC
Other - Org Name:SHARE WELLNESS URGENT MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:501-837-3680
Mailing Address - Street 1:415 E PLEASANT RUN RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-1875
Mailing Address - Country:US
Mailing Address - Phone:972-293-9660
Mailing Address - Fax:972-293-9669
Practice Address - Street 1:415 E PLEASANT RUN RD
Practice Address - Street 2:SUITE 125
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-1875
Practice Address - Country:US
Practice Address - Phone:972-293-9660
Practice Address - Fax:972-293-9669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-12
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2485261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX327897Medicare PIN