Provider Demographics
NPI:1134495245
Name:HEALTHSTAT WELLNESS-POLK HAINES
Entity Type:Organization
Organization Name:HEALTHSTAT WELLNESS-POLK HAINES
Other - Org Name:HEALTHSTAT ON-SITE CLINIC/POLK COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF RISK MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-936-5546
Mailing Address - Street 1:4601 CHARLOTTE PARK DR
Mailing Address - Street 2:SUITE 390
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1915
Mailing Address - Country:US
Mailing Address - Phone:704-529-6161
Mailing Address - Fax:704-936-5570
Practice Address - Street 1:631B US HIGHWAY 17 92 W
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-5047
Practice Address - Country:US
Practice Address - Phone:863-519-3858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty
No3336C0002XSuppliersPharmacyClinic PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5709730OtherNCPDP PROVIDER IDENTIFICATION NUMBER