Provider Demographics
NPI:1215613419
Name:CHARLOTTE HARBOR WELLNESS P A
Entity type:Organization
Organization Name:CHARLOTTE HARBOR WELLNESS P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TETYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:METYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-613-1919
Mailing Address - Street 1:3191 HARBOR BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6755
Mailing Address - Country:US
Mailing Address - Phone:941-613-1919
Mailing Address - Fax:
Practice Address - Street 1:2811 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5173
Practice Address - Country:US
Practice Address - Phone:941-613-1919
Practice Address - Fax:941-613-4077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-23
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty