Provider Demographics
NPI:1639404643
Name:THE CLINIC AT WALMART OPERATED BY WUESTHOFF HEALTH SYSTEM, LLC
Entity Type:Organization
Organization Name:THE CLINIC AT WALMART OPERATED BY WUESTHOFF HEALTH SYSTEM, LLC
Other - Org Name:CLINIC AT WALMART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ASSISTANT WFP
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-449-4534
Mailing Address - Street 1:150 N SYKES CREEK PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-3488
Mailing Address - Country:US
Mailing Address - Phone:321-449-4534
Mailing Address - Fax:321-449-4164
Practice Address - Street 1:1500 E MERRITT ISLAND CSWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-2612
Practice Address - Country:US
Practice Address - Phone:321-449-4534
Practice Address - Fax:321-449-4164
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WUESTHOFF FAMILY PHYSICIANS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty