Provider Demographics
NPI:1902269715
Name:COMMUNITY WELLNESS CLINIC, LLP
Entity type:Organization
Organization Name:COMMUNITY WELLNESS CLINIC, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-760-2797
Mailing Address - Street 1:201 ENTERPRISE ROW
Mailing Address - Street 2:SUITE 12
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-4448
Mailing Address - Country:US
Mailing Address - Phone:936-760-2784
Mailing Address - Fax:936-760-1950
Practice Address - Street 1:201 ENTERPRISE ROW
Practice Address - Street 2:SUITE 12
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-4448
Practice Address - Country:US
Practice Address - Phone:936-760-2784
Practice Address - Fax:936-760-1950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning FacilityGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018986205Medicaid