1902218183 NPI number — PREMIER WELLNESS CENTERS OF STUART LLC

Table of content: (NPI 1902218183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902218183 NPI number — PREMIER WELLNESS CENTERS OF STUART LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER WELLNESS CENTERS OF STUART LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902218183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10050 SW INNOVATION WAY
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34987-2117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-879-8700
Provider Business Mailing Address Fax Number:
772-879-8710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2155 SE FEDERAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-4514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-201-0500
Provider Business Practice Location Address Fax Number:
772-201-0501
Provider Enumeration Date:
05/22/2014

Additional Information

Authorized Official

Authorized Official Last Name:
JENSEN
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
772-879-8700

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH10127 , 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)





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