Provider Demographics
NPI:1164897468
Name:BRANDON WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:BRANDON WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-574-9206
Mailing Address - Street 1:902 W LUMSDEN RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8806
Mailing Address - Country:US
Mailing Address - Phone:813-574-9206
Mailing Address - Fax:813-714-7575
Practice Address - Street 1:902 W LUMSDEN RD
Practice Address - Street 2:SUITE 104
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-8806
Practice Address - Country:US
Practice Address - Phone:813-574-9206
Practice Address - Fax:813-714-7575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10346111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty