Provider Demographics
NPI:1306246319
Name:DEYARD WELLNESS CENTER
Entity type:Organization
Organization Name:DEYARD WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:YARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-322-3505
Mailing Address - Street 1:1728 DUNLAWTON AVE
Mailing Address - Street 2:STE 2
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-2922
Mailing Address - Country:US
Mailing Address - Phone:386-322-3505
Mailing Address - Fax:386-322-3509
Practice Address - Street 1:1728 DUNLAWTON AVE
Practice Address - Street 2:STE 2
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-2922
Practice Address - Country:US
Practice Address - Phone:386-322-3505
Practice Address - Fax:386-322-3509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68224302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization