Provider Demographics
NPI:1093969024
Name:A PRESTIGE WELLNESS CENTER, PA
Entity Type:Organization
Organization Name:A PRESTIGE WELLNESS CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-433-2005
Mailing Address - Street 1:3650 NW 82 AVE
Mailing Address - Street 2:SUITE #503
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166
Mailing Address - Country:US
Mailing Address - Phone:305-433-2005
Mailing Address - Fax:305-591-8020
Practice Address - Street 1:3650 NW 82 AVE
Practice Address - Street 2:SUITE #503
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166
Practice Address - Country:US
Practice Address - Phone:305-433-2005
Practice Address - Fax:305-591-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
FLME96872207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273654301Medicaid
I62978Medicare UPIN
FL273654301Medicaid