Provider Demographics
NPI:1639322712
Name:PREMIER WELLNESS CENTERS LLC
Entity Type:Organization
Organization Name:PREMIER WELLNESS CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-879-8700
Mailing Address - Street 1:10050 SW INNOVATION WAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2117
Mailing Address - Country:US
Mailing Address - Phone:772-879-8700
Mailing Address - Fax:772-879-8710
Practice Address - Street 1:10050 SW INNOVATION WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2117
Practice Address - Country:US
Practice Address - Phone:772-879-8700
Practice Address - Fax:772-879-8710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-03
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8221111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1992919922OtherNPI