Provider Demographics
NPI:1639990831
Name:AMELIA ISLAND SENIOR WELLNESS LLC
Entity type:Organization
Organization Name:AMELIA ISLAND SENIOR WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUBER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:804-543-3724
Mailing Address - Street 1:2782 PARK SQUARE PL E
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-8933
Mailing Address - Country:US
Mailing Address - Phone:804-543-3724
Mailing Address - Fax:904-601-1495
Practice Address - Street 1:2782 PARK SQUARE PL E
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-8933
Practice Address - Country:US
Practice Address - Phone:804-543-3724
Practice Address - Fax:904-601-1495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty