Provider Demographics
NPI:1245616192
Name:CENTRAL PARC WELLNESS
Entity Type:Organization
Organization Name:CENTRAL PARC WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LANE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-804-9494
Mailing Address - Street 1:920 INTERNATIONAL PKWY
Mailing Address - Street 2:SUITE # 1056
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5219
Mailing Address - Country:US
Mailing Address - Phone:407-915-5300
Mailing Address - Fax:407-915-6334
Practice Address - Street 1:920 INTERNATIONAL PKWY
Practice Address - Street 2:SUITE # 1056
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5219
Practice Address - Country:US
Practice Address - Phone:407-915-5300
Practice Address - Fax:407-915-6334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-03
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty