Provider Demographics
NPI:1821423138
Name:WELLNESS CLINICAL CENTER, INC
Entity Type:Organization
Organization Name:WELLNESS CLINICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LISMELYS
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUJILLO GAMA
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:786-227-5000
Mailing Address - Street 1:11285 SW 211TH ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33189-2211
Mailing Address - Country:US
Mailing Address - Phone:786-227-5000
Mailing Address - Fax:305-378-9968
Practice Address - Street 1:11285 SW 211TH ST
Practice Address - Street 2:SUITE 205
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33189-2211
Practice Address - Country:US
Practice Address - Phone:786-227-5000
Practice Address - Fax:305-378-9968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service