Provider Demographics
NPI:1124372420
Name:WILMAR MEDICAL CORP
Entity Type:Organization
Organization Name:WILMAR MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILL
Authorized Official - Middle Name:
Authorized Official - Last Name:INNOCENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-290-4144
Mailing Address - Street 1:PO BOX 221313
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33422-1313
Mailing Address - Country:US
Mailing Address - Phone:561-290-4144
Mailing Address - Fax:
Practice Address - Street 1:4849 LAKE WORTH RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-3455
Practice Address - Country:US
Practice Address - Phone:561-290-4144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92937261Q00000X
FLME93404261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center