Provider Demographics
NPI:1912286287
Name:GWYN FELLER, DOM, AP, LLC
Entity Type:Organization
Organization Name:GWYN FELLER, DOM, AP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GWYN
Authorized Official - Middle Name:PURDUE
Authorized Official - Last Name:FELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DOM, AP
Authorized Official - Phone:727-458-3942
Mailing Address - Street 1:10919 111TH ST
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-4004
Mailing Address - Country:US
Mailing Address - Phone:727-458-3942
Mailing Address - Fax:
Practice Address - Street 1:2575 HARN BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-3211
Practice Address - Country:US
Practice Address - Phone:727-458-3942
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2804171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty