Provider Demographics
NPI:1053656702
Name:SOMERVILLE HEALTH AND WELLNESS, LLC
Entity Type:Organization
Organization Name:SOMERVILLE HEALTH AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-965-8665
Mailing Address - Street 1:2324 S CONGRESS AVE STE 1J
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-7667
Mailing Address - Country:US
Mailing Address - Phone:561-965-8665
Mailing Address - Fax:
Practice Address - Street 1:2324 S CONGRESS AVE STE 1J
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-7667
Practice Address - Country:US
Practice Address - Phone:561-965-8665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3815650-00Medicaid
FL3815650-00Medicaid