Provider Demographics
NPI:1235587676
Name:IDEAL HEALTH AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:IDEAL HEALTH AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-933-1511
Mailing Address - Street 1:8001 N DALE MABRY HWY BLDG 301
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-3290
Mailing Address - Country:US
Mailing Address - Phone:813-933-1511
Mailing Address - Fax:
Practice Address - Street 1:8001 N DALE MABRY HWY BLDG 301
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-3290
Practice Address - Country:US
Practice Address - Phone:813-933-1511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty