Provider Demographics
NPI:1245759596
Name:LARGO WELLNESS PRIMARY CARE
Entity Type:Organization
Organization Name:LARGO WELLNESS PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICKORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-420-7501
Mailing Address - Street 1:415 7TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 7TH AVE SW
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3400
Practice Address - Country:US
Practice Address - Phone:727-501-1040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-18
Last Update Date:2018-09-26
Deactivation Date:2018-08-15
Deactivation Code:
Reactivation Date:2018-09-26
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty