Provider Demographics
NPI:1275854564
Name:HEALTHY-GLOW WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:HEALTHY-GLOW WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:MR
Authorized Official - First Name:GUILDFORD
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:813-449-4414
Mailing Address - Street 1:4511 N HIMES AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7074
Mailing Address - Country:US
Mailing Address - Phone:813-449-4414
Mailing Address - Fax:813-873-2330
Practice Address - Street 1:4511 N HIMES AVE
Practice Address - Street 2:STE 200
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7074
Practice Address - Country:US
Practice Address - Phone:813-449-4414
Practice Address - Fax:813-873-2330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-21
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 57747174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty