Provider Demographics
NPI:1285093179
Name:FLAGLER SQUARE WELLNESS CENTER
Entity type:Organization
Organization Name:FLAGLER SQUARE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:305-698-4000
Mailing Address - Street 1:1840 FOREST HILL BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAKE CLARKE SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33406-6063
Mailing Address - Country:US
Mailing Address - Phone:305-698-4000
Mailing Address - Fax:305-698-4014
Practice Address - Street 1:1840 FOREST HILL BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKE CLARKE SHORES
Practice Address - State:FL
Practice Address - Zip Code:33406-6063
Practice Address - Country:US
Practice Address - Phone:305-698-4000
Practice Address - Fax:305-698-4014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6297261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center