Provider Demographics
NPI:1629597869
Name:GARDEN LIFE WELLNESS, LLC
Entity Type:Organization
Organization Name:GARDEN LIFE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:KUKEC
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:561-420-7244
Mailing Address - Street 1:401 N ROSEMARY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-4133
Mailing Address - Country:US
Mailing Address - Phone:561-420-7244
Mailing Address - Fax:
Practice Address - Street 1:401 N ROSEMARY AVE
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401
Practice Address - Country:US
Practice Address - Phone:561-420-7244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone