Provider Demographics
NPI:1013456805
Name:DE LA ROSA WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:DE LA ROSA WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-360-2046
Mailing Address - Street 1:7392 NW 35TH TER STE 310
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33122-1260
Mailing Address - Country:US
Mailing Address - Phone:786-360-2046
Mailing Address - Fax:
Practice Address - Street 1:7392 NW 35TH TER STE 310
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33122-1260
Practice Address - Country:US
Practice Address - Phone:786-360-2046
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA35823261Q00000X, 261QP2000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation