OLD CORNER WELLNESS INC — NPI 1003514597 (Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Adult Health in WEST, TX)

CMS-1500 Box 24J / 33a • NPI

1003514597

Type 2 Organization (Box 32a/33a)

HIPAA NUCC Taxonomy • CMS Code

363LA2200X (CMS 50)

Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Adult Health

Box 32 Service Location & ZIP+4

200 N MAIN ST, WEST, TX, 76691-1207

✓ 9-Digit EDI 837 ZIP+4 (76691-1207)

Practice Phone & Referral Fax

(254) 826-5122

Direct NPPES Verification Line

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1003514597 (OLD CORNER WELLNESS INC) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

Institutional Type-2 NPI facilities enroll via CMS-855A institutional provider agreements rather than individual Order & Referring PECOS.

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1003514597` (NPI-2 Organization / Facility)
Provider / Legal Name	OLD CORNER WELLNESS INC
Plain-English Specialty	Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Adult Health NUCC Code: `363LA2200X` (Nurse Practitioner, Adult Health)
Certifying / Licensing Body	State Medical / Healthcare Licensing Board & National Specialty Board
Practice Location Address	200 N MAIN ST, WEST, TX, 76691-1207
Practice Telephone / Fax	Tel: (254) 826-5122
Administrative Mailing Address	200 N MAIN ST, WEST, TX, 76691-1207
Enumeration & Last Sync	Enumerated: 2023-02-23 \| CMS Record Updated: 2024-06-04
Authorized Official	RANDY NIEMEYER (Owner)

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

200 N MAIN ST, WEST, TX, 76691-1207

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Plain-English Taxonomy & CMS Crosswalk (363LA2200X)

What Does Taxonomy Code 363LA2200X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 363LA2200X translates to:
"Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Adult Health"

CMS-1500 Medicare Specialty Crosswalk: CMS Code 50 (Nurse Practitioner)
Certifying / Accrediting Authority: State Medical / Healthcare Licensing Board & National Specialty Board
Clinical Scope: Consult a verified Nurse Practitioner, Adult Health for specialized diagnostic evaluation, treatment planning, and continuity of care.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (OLD CORNER WELLNESS INC)

Typical CPT / Diagnostic Procedures:

Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
Preventive Screening, Patient Counseling & Multidisciplinary Referral

Common Therapeutic Classes:

Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`261Q00000X` — Clinic/Center Plain English: Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center	State: N/A \| License: `Verified` \| Primary: Secondary
`363LA2200X` — Nurse Practitioner, Adult Health Plain English: Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Nurse Practitioner, Adult Health	State: N/A \| License: `Verified` \| Primary: Yes (Primary)

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OLD CORNER WELLNESS INC (NPI #1003514597)