Provider Demographics
NPI:1528365145
Name:WELLCARE CLINIC INC
Entity Type:Organization
Organization Name:WELLCARE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEYTTIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SARDINAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-300-6925
Mailing Address - Street 1:11865 SW 26TH ST
Mailing Address - Street 2:B-14
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-2400
Mailing Address - Country:US
Mailing Address - Phone:305-300-6925
Mailing Address - Fax:305-675-2668
Practice Address - Street 1:11865 SW 26TH ST
Practice Address - Street 2:B-14
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-2400
Practice Address - Country:US
Practice Address - Phone:305-300-6925
Practice Address - Fax:305-675-2668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC8906261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFILE 9187OtherAHCA EXEMPT HCC UNIT