Provider Demographics
NPI:1194188656
Name:FOUNDATIONS WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:FOUNDATIONS WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:THAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-361-6778
Mailing Address - Street 1:160 NW CENTRAL PARK PLZ STE 110
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1825
Mailing Address - Country:US
Mailing Address - Phone:772-812-6852
Mailing Address - Fax:
Practice Address - Street 1:160 NW CENTRAL PARK PLZ STE 110
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1825
Practice Address - Country:US
Practice Address - Phone:772-812-6852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5601324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility