Provider Demographics
NPI:1578210332
Name:MWL-PB-BR-LLC
Entity Type:Organization
Organization Name:MWL-PB-BR-LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOMMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-383-3848
Mailing Address - Street 1:2466 E COMMERCIAL BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4011
Mailing Address - Country:US
Mailing Address - Phone:754-216-7177
Mailing Address - Fax:
Practice Address - Street 1:2466 E COMMERCIAL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4011
Practice Address - Country:US
Practice Address - Phone:754-216-7177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty