Provider Demographics
NPI:1013147834
Name:WC WELLNESS LLC
Entity Type:Organization
Organization Name:WC WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:DETOURNILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-241-0303
Mailing Address - Street 1:600 SW 3RD ST
Mailing Address - Street 2:SUITE 2270
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-6932
Mailing Address - Country:US
Mailing Address - Phone:954-241-0303
Mailing Address - Fax:
Practice Address - Street 1:600 SW 3RD ST
Practice Address - Street 2:SUITE 2270
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-6932
Practice Address - Country:US
Practice Address - Phone:954-241-0303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME630702084P0800X
FLARNP1348922363LP0808X
FLARNP2053552363LP0808X
FLARNP2876402363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty