Provider Demographics
NPI:1154723823
Name:DATE WELLNESS CENTER INC
Entity type:Organization
Organization Name:DATE WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-974-5683
Mailing Address - Street 1:5190 NW 167TH ST
Mailing Address - Street 2:STE 308
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-6328
Mailing Address - Country:US
Mailing Address - Phone:305-974-5683
Mailing Address - Fax:305-646-1361
Practice Address - Street 1:5190 NW 167TH ST
Practice Address - Street 2:STE 308
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-6328
Practice Address - Country:US
Practice Address - Phone:305-974-5683
Practice Address - Fax:305-646-1361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12303261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service