Provider Demographics
NPI:1114346574
Name:WELLNESS AND HORMONE CENTERS OF AMERICA PALM BEACH COUNTY I, LLC
Entity Type:Organization
Organization Name:WELLNESS AND HORMONE CENTERS OF AMERICA PALM BEACH COUNTY I, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-820-0543
Mailing Address - Street 1:5030 CHAMPION BLVD
Mailing Address - Street 2:SUITES C2/C3
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2473
Mailing Address - Country:US
Mailing Address - Phone:855-336-1296
Mailing Address - Fax:
Practice Address - Street 1:5030 CHAMPION BLVD
Practice Address - Street 2:SUITES C2/C3
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-2473
Practice Address - Country:US
Practice Address - Phone:855-336-1296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47330261QH0100X
FLME54115261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE66207Medicare PIN