Provider Demographics
NPI:1811529530
Name:OAKLAND PARK WELLNESS CENTER
Entity type:Organization
Organization Name:OAKLAND PARK WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KODZIK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:954-309-5736
Mailing Address - Street 1:3857 POWERLINE RD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-5067
Mailing Address - Country:US
Mailing Address - Phone:954-635-2900
Mailing Address - Fax:
Practice Address - Street 1:3857 POWERLINE RD
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-5067
Practice Address - Country:US
Practice Address - Phone:954-635-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1073654281Medicaid
FL1316344484Medicaid