Provider Demographics
NPI:1063006088
Name:PREMIER WELLNESS CENTERS PSL
Entity Type:Organization
Organization Name:PREMIER WELLNESS CENTERS PSL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-879-8100
Mailing Address - Street 1:7043 S US HIGHWAY 1 STE 100
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-1401
Mailing Address - Country:US
Mailing Address - Phone:772-879-8100
Mailing Address - Fax:772-879-8101
Practice Address - Street 1:7043 S US HIGHWAY 1 STE 100
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-1401
Practice Address - Country:US
Practice Address - Phone:772-879-8100
Practice Address - Fax:772-879-8101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty