Provider Demographics
NPI:1710152897
Name:ST. JOHNS WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:ST. JOHNS WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:L
Authorized Official - Last Name:TORROLL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:904-537-0674
Mailing Address - Street 1:4361 COMANCHE TRAIL BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-4285
Mailing Address - Country:US
Mailing Address - Phone:904-537-0674
Mailing Address - Fax:
Practice Address - Street 1:305 KINGSLEY LAKE DR
Practice Address - Street 2:SUITE 702
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3043
Practice Address - Country:US
Practice Address - Phone:904-537-0674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM18687174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty