Provider Demographics
NPI:1104657592
Name:DFW COMMUNITY BIRTH & WELLNESS, LLC
Entity type:Organization
Organization Name:DFW COMMUNITY BIRTH & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:FEWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LM, CPM
Authorized Official - Phone:214-699-8659
Mailing Address - Street 1:4612 GASTON AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4612 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1010
Practice Address - Country:US
Practice Address - Phone:214-699-8659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1932637113Medicaid