Provider Demographics
NPI:1154816510
Name:KERSENBROCK MEDICAL AND WELLNESS, LLC
Entity type:Organization
Organization Name:KERSENBROCK MEDICAL AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:KERSENBROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-732-6920
Mailing Address - Street 1:760 CURRENCY CIR STE A
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2138
Mailing Address - Country:US
Mailing Address - Phone:407-732-6920
Mailing Address - Fax:407-732-6923
Practice Address - Street 1:760 CURRENCY CIR STE A
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2138
Practice Address - Country:US
Practice Address - Phone:407-732-6920
Practice Address - Fax:407-732-6923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty