# GRAPEVINE TOTAL WELLNESS PLLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** MODERN MALE T-CLINIC, P.A.
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1215594577
- **Legal business name:** MODERN MALE T-CLINIC, P.A.
- **Authorized official:** SALVATORE CAMPO DO (PHYSICIAN/PRESIDENT)
- **Authorized official phone:** (800) 246-5698

## Contact information

- **Practice address:** 1000 W ST HWY 114, GRAPEVINE, TX 76051-3987
- **Practice address phone:** (800) 246-5698
- **Mailing address:** 5000 ELDORADO PKWY STE 150-153, FRISCO, TX 75033-8695
- **Mailing address phone:** (800) 246-5698

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207QA0505X | Adult Medicine Physician | — | NULL | Yes |
| 207QA0505X | Adult Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 05/22/2019
- **Last updated:** 06/11/2019