Provider Demographics
NPI:1053883405
Name:COSMEDIC WELLNESS CENTERS, INC
Entity type:Organization
Organization Name:COSMEDIC WELLNESS CENTERS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:KREPINEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-579-2660
Mailing Address - Street 1:1030 E HWY 377 STE 114
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1457
Mailing Address - Country:US
Mailing Address - Phone:817-579-2660
Mailing Address - Fax:877-456-6014
Practice Address - Street 1:1030 E HWY 377 STE 114
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1457
Practice Address - Country:US
Practice Address - Phone:817-579-2660
Practice Address - Fax:877-465-6014
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COSMEDIC WELLNESS CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-26
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126628003Medicaid