Provider Demographics
NPI:1851661334
Name:ADVANCED SPINE AND WELLNESS
Entity Type:Organization
Organization Name:ADVANCED SPINE AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:LEMMON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:863-293-0040
Mailing Address - Street 1:1125 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3902
Mailing Address - Country:US
Mailing Address - Phone:863-293-0040
Mailing Address - Fax:863-294-1419
Practice Address - Street 1:1125 1ST ST S
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3902
Practice Address - Country:US
Practice Address - Phone:863-293-0040
Practice Address - Fax:863-294-1419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 9923332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies