Provider Demographics
NPI:1598300543
Name:PREMIER WELLNESS MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:PREMIER WELLNESS MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOSVANY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ LEMUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-834-9626
Mailing Address - Street 1:2780 SW 87TH AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3296
Mailing Address - Country:US
Mailing Address - Phone:786-817-2979
Mailing Address - Fax:786-409-2024
Practice Address - Street 1:2780 SW 87TH AVE STE 108
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3296
Practice Address - Country:US
Practice Address - Phone:786-817-2979
Practice Address - Fax:786-409-2024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS15495OtherOSTEOPATHIC PHYSICIAN MEDICAL LICENSE