Provider Demographics
NPI:1083063176
Name:EMBRACING LIFE WELLNESS CENTER, PA
Entity Type:Organization
Organization Name:EMBRACING LIFE WELLNESS CENTER, PA
Other - Org Name:MELISSA VILARDEBO, MD, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:FICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-662-5919
Mailing Address - Street 1:6332 US HIGHWAY 301 S
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-3829
Mailing Address - Country:US
Mailing Address - Phone:813-662-5919
Mailing Address - Fax:813-671-8374
Practice Address - Street 1:6332 US HIGHWAY 301 S
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3829
Practice Address - Country:US
Practice Address - Phone:813-662-5919
Practice Address - Fax:813-671-8374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME962972084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty