Provider Demographics
NPI:1902180789
Name:WILLA CARSON HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:WILLA CARSON HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TYRELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:727-467-9411
Mailing Address - Street 1:1108 N MARTIN LUTHER KING JR AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-3222
Mailing Address - Country:US
Mailing Address - Phone:727-467-9411
Mailing Address - Fax:727-467-2771
Practice Address - Street 1:1108 N MARTIN LUTHER KING JR AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-3222
Practice Address - Country:US
Practice Address - Phone:727-467-9411
Practice Address - Fax:727-467-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty