Provider Demographics
NPI:1558984971
Name:NEW IDENTITY WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:NEW IDENTITY WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERS
Authorized Official - Prefix:
Authorized Official - First Name:CARILYN/LENON
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ/JUAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-804-9405
Mailing Address - Street 1:14601 SW 29TH ST STE 107
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-4715
Mailing Address - Country:US
Mailing Address - Phone:786-804-9405
Mailing Address - Fax:
Practice Address - Street 1:14601 SW 29TH ST STE 107
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-4715
Practice Address - Country:US
Practice Address - Phone:786-804-9405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-20
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health