Provider Demographics
NPI:1063959187
Name:MEDICAL WELLNESS GROUP, INC.
Entity type:Organization
Organization Name:MEDICAL WELLNESS GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:LE ROY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:760-360-8700
Mailing Address - Street 1:41749 BROWNSTOWN DR
Mailing Address - Street 2:
Mailing Address - City:BERMUDA DUNES
Mailing Address - State:CA
Mailing Address - Zip Code:92203-1042
Mailing Address - Country:US
Mailing Address - Phone:760-636-9893
Mailing Address - Fax:
Practice Address - Street 1:41749 BROWNSTOWN DR
Practice Address - Street 2:
Practice Address - City:BERMUDA DUNES
Practice Address - State:CA
Practice Address - Zip Code:92203-1042
Practice Address - Country:US
Practice Address - Phone:760-636-9893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3978244208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty