Provider Demographics
NPI:1154805828
Name:SOUTH CENTRAL WELLNESS LLC
Entity type:Organization
Organization Name:SOUTH CENTRAL WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:LIANE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-651-0702
Mailing Address - Street 1:5859 FERGUS
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-8627
Mailing Address - Country:US
Mailing Address - Phone:512-651-0702
Mailing Address - Fax:512-651-0702
Practice Address - Street 1:1180 SETON PKWY STE 320
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640
Practice Address - Country:US
Practice Address - Phone:512-651-0702
Practice Address - Fax:512-651-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty