Provider Demographics
NPI:1417252131
Name:CLINICAID WELL CENTER, LLC
Entity Type:Organization
Organization Name:CLINICAID WELL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CEBALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:813-874-2737
Mailing Address - Street 1:3619 HENDERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4501
Mailing Address - Country:US
Mailing Address - Phone:813-874-2737
Mailing Address - Fax:813-874-0099
Practice Address - Street 1:3619 HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4501
Practice Address - Country:US
Practice Address - Phone:813-874-2737
Practice Address - Fax:813-874-0099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8834273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit