Provider Demographics
NPI:1851579320
Name:SOUTH LAKE WELLNESS & INJURY CENTER, PL
Entity Type:Organization
Organization Name:SOUTH LAKE WELLNESS & INJURY CENTER, PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-241-4111
Mailing Address - Street 1:2745 CITRUS TOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6699
Mailing Address - Country:US
Mailing Address - Phone:352-241-4111
Mailing Address - Fax:352-241-4113
Practice Address - Street 1:2745 CITRUS TOWER BLVD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6699
Practice Address - Country:US
Practice Address - Phone:352-241-4111
Practice Address - Fax:352-241-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0007823111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6551Medicare PIN