Provider Demographics
NPI:1013163781
Name:FAMILY WELLNESS CENTER OF TAMPA PA
Entity Type:Organization
Organization Name:FAMILY WELLNESS CENTER OF TAMPA PA
Other - Org Name:LASERMEDIC, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:KAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-994-0611
Mailing Address - Street 1:2734 WINDGUARD CIR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-7362
Mailing Address - Country:US
Mailing Address - Phone:813-994-0611
Mailing Address - Fax:813-994-0085
Practice Address - Street 1:2734 WINDGUARD CIR
Practice Address - Street 2:SUITE 102
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-7362
Practice Address - Country:US
Practice Address - Phone:813-994-0611
Practice Address - Fax:813-994-0085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88978261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009566500Medicaid
FL009565000Medicaid
FLC93008Medicare UPIN