1114346574 NPI number — WELLNESS AND HORMONE CENTERS OF AMERICA PALM BEACH COUNTY I, LLC

Table of content: (NPI 1114346574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114346574 NPI number — WELLNESS AND HORMONE CENTERS OF AMERICA PALM BEACH COUNTY I, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLNESS AND HORMONE CENTERS OF AMERICA PALM BEACH COUNTY I, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
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NPI Number Information

NPI Number:
1114346574
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5030 CHAMPION BLVD
Provider Second Line Business Mailing Address:
SUITES C2/C3
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33496-2473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-336-1296
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5030 CHAMPION BLVD
Provider Second Line Business Practice Location Address:
SUITES C2/C3
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33496-2473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-336-1296
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILEY
Authorized Official First Name:
GAIL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER OF OPERATIONS
Authorized Official Telephone Number:
715-820-0543

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  ME47330 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: ME54115 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)