Provider Demographics
NPI:1790155455
Name:THE BENJAMIN WELLNESS CENTER SOUTH
Entity Type:Organization
Organization Name:THE BENJAMIN WELLNESS CENTER SOUTH
Other - Org Name:BENJAMIN OUTREACH MEDICAL NETWORK CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:ILNISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-251-0267
Mailing Address - Street 1:10300 SUNSET DR
Mailing Address - Street 2:STE #280
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-3012
Mailing Address - Country:US
Mailing Address - Phone:305-901-2209
Mailing Address - Fax:305-901-2189
Practice Address - Street 1:10300 SUNSET DR
Practice Address - Street 2:STE #280
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3012
Practice Address - Country:US
Practice Address - Phone:305-901-2209
Practice Address - Fax:305-901-2189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENJAMIN OUTREACH MEDICAL NETWORK CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty