Provider Demographics
NPI:1043636822
Name:JACKSONVILLE WELLNESS CENTER & PREVENTIVE MEDICINE CLINIC
Entity Type:Organization
Organization Name:JACKSONVILLE WELLNESS CENTER & PREVENTIVE MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-388-7968
Mailing Address - Street 1:2317 BLANDING BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-4194
Mailing Address - Country:US
Mailing Address - Phone:904-388-7968
Mailing Address - Fax:904-425-7889
Practice Address - Street 1:3604 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4241
Practice Address - Country:US
Practice Address - Phone:904-563-5838
Practice Address - Fax:904-425-7889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME57227207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty