Provider Demographics
NPI:1770722936
Name:MEDICAL AND WELLNESS CENTER OF MELROSE CORPORATION
Entity type:Organization
Organization Name:MEDICAL AND WELLNESS CENTER OF MELROSE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KENYETTA
Authorized Official - Middle Name:LATRICE
Authorized Official - Last Name:REESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-478-2471
Mailing Address - Street 1:1745 SR 100
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:FL
Mailing Address - Zip Code:32666
Mailing Address - Country:US
Mailing Address - Phone:352-478-2471
Mailing Address - Fax:352-478-2496
Practice Address - Street 1:1745 SR 100
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:FL
Practice Address - Zip Code:32666
Practice Address - Country:US
Practice Address - Phone:954-854-4290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP780412261QH0100X
FLACN205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty