Provider Demographics
NPI:1568475366
Name:GRAND PRAIRIE WELLNESS CTR
Entity type:Organization
Organization Name:GRAND PRAIRIE WELLNESS CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:POFFENBARGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-266-9123
Mailing Address - Street 1:1710 SMALL ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-6041
Mailing Address - Country:US
Mailing Address - Phone:972-266-9123
Mailing Address - Fax:972-266-7383
Practice Address - Street 1:1710 SMALL ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-6041
Practice Address - Country:US
Practice Address - Phone:972-266-9123
Practice Address - Fax:972-266-7383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00261ZMedicare ID - Type UnspecifiedPROVIDER NUMBER