Provider Demographics
NPI:1710574413
Name:PERSONALIZED AND RESTORATIVE WELLNESS PA
Entity Type:Organization
Organization Name:PERSONALIZED AND RESTORATIVE WELLNESS PA
Other - Org Name:PRESTIGE INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-517-8678
Mailing Address - Street 1:1002 S OLD DIXIE HWY STE 204
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-7202
Mailing Address - Country:US
Mailing Address - Phone:561-517-8678
Mailing Address - Fax:561-529-5082
Practice Address - Street 1:1002 S OLD DIXIE HWY STE 204
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7202
Practice Address - Country:US
Practice Address - Phone:561-517-8678
Practice Address - Fax:561-529-5082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-29
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty