Provider Demographics
NPI:1831763762
Name:WELLNESS MEDICAL GROUP LLC
Entity type:Organization
Organization Name:WELLNESS MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANABEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-746-5424
Mailing Address - Street 1:9600 NW 25TH ST STE 6A
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1416
Mailing Address - Country:US
Mailing Address - Phone:305-631-2095
Mailing Address - Fax:
Practice Address - Street 1:2500 NW 79TH AVE STE 233
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33122-1086
Practice Address - Country:US
Practice Address - Phone:786-209-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-15
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management