Provider Demographics
NPI:1760107130
Name:WELLNESS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:WELLNESS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANABEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-746-5424
Mailing Address - Street 1:4440 PGA BLVD STE 410
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-6544
Mailing Address - Country:US
Mailing Address - Phone:786-569-3793
Mailing Address - Fax:
Practice Address - Street 1:4440 PGA BLVD STE 410
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-6544
Practice Address - Country:US
Practice Address - Phone:786-569-3793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLNESS MEDICAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)