Provider Demographics
NPI:1346719812
Name:SHEKINAH HEALTH & WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:SHEKINAH HEALTH & WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOLINE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLANC
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:561-317-8454
Mailing Address - Street 1:305 CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8181
Mailing Address - Country:US
Mailing Address - Phone:561-317-8454
Mailing Address - Fax:
Practice Address - Street 1:305 CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8181
Practice Address - Country:US
Practice Address - Phone:561-317-8454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty