Provider Demographics
NPI:1801676556
Name:FAMILY MEDICAL CLINIC AND WELLNESS LLC
Entity type:Organization
Organization Name:FAMILY MEDICAL CLINIC AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KOWALCZYK VITOUS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-C
Authorized Official - Phone:561-714-7432
Mailing Address - Street 1:7736 GREENBRIER CIR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3301
Mailing Address - Country:US
Mailing Address - Phone:561-714-7432
Mailing Address - Fax:
Practice Address - Street 1:207 NW SAINT JAMES DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1291
Practice Address - Country:US
Practice Address - Phone:772-710-8583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty