Provider Demographics
NPI:1457368086
Name:HEALTH & WELLNESS CENTER OF PORT ST. LUCIE
Entity Type:Organization
Organization Name:HEALTH & WELLNESS CENTER OF PORT ST. LUCIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIEMBA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-337-3141
Mailing Address - Street 1:8423 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3358
Mailing Address - Country:US
Mailing Address - Phone:772-337-3141
Mailing Address - Fax:772-878-1559
Practice Address - Street 1:8423 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3358
Practice Address - Country:US
Practice Address - Phone:772-337-3141
Practice Address - Fax:772-878-1559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCHOOO6248111N00000X
FLCHOOO6729111N00000X
FLOS6560207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicare ID - Type Unspecified