Provider Demographics
NPI:1861917734
Name:WELLNESS CARE CENTER OF IRVING, LTD
Entity type:Organization
Organization Name:WELLNESS CARE CENTER OF IRVING, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:DURHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-831-2541
Mailing Address - Street 1:111 FERGUSON CT
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-7014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 FERGUSON CT
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-7014
Practice Address - Country:US
Practice Address - Phone:972-353-5437
Practice Address - Fax:800-669-2161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-11
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287022201Medicaid