Provider Demographics
NPI:1336247634
Name:NORTH PALM BEACH MEDICAL WELLNESS CENTER LLC
Entity type:Organization
Organization Name:NORTH PALM BEACH MEDICAL WELLNESS CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:FENN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-626-5433
Mailing Address - Street 1:11911 US HIGHWAY 1
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-2827
Mailing Address - Country:US
Mailing Address - Phone:561-626-5433
Mailing Address - Fax:561-626-3371
Practice Address - Street 1:11911 US HIGHWAY 1
Practice Address - Street 2:SUITE 102
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-2827
Practice Address - Country:US
Practice Address - Phone:561-626-5433
Practice Address - Fax:561-626-3371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5263111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76037OtherBCBS GROUP
FLAI254Medicare PIN