Provider Demographics
NPI:1073075974
Name:SEMINOLE WELLNESS & INJURY CENTER
Entity Type:Organization
Organization Name:SEMINOLE WELLNESS & INJURY CENTER
Other - Org Name:SEMINOLE INTEGRATIVE MEDICINE, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOCCO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-831-4357
Mailing Address - Street 1:164 SAUSALITO BLVD
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-5764
Mailing Address - Country:US
Mailing Address - Phone:407-831-4357
Mailing Address - Fax:
Practice Address - Street 1:164 SAUSALITO BLVD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-5764
Practice Address - Country:US
Practice Address - Phone:407-831-4357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-01
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1871663807OtherNATIONAL PROVIDER NU,BER