Provider Demographics
NPI:1902684293
Name:FAMILY WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:FAMILY WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:985-714-9087
Mailing Address - Street 1:1234 DAVID DR STE 103
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70380-1369
Mailing Address - Country:US
Mailing Address - Phone:985-221-4436
Mailing Address - Fax:985-221-4567
Practice Address - Street 1:1234 DAVID DR STE 103
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1369
Practice Address - Country:US
Practice Address - Phone:985-221-4436
Practice Address - Fax:985-221-4567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty