Provider Demographics
NPI:1487329348
Name:INTEGRATIVE WELLNESS CENTERS OF PORT CHARLOTTE, LLC
Entity type:Organization
Organization Name:INTEGRATIVE WELLNESS CENTERS OF PORT CHARLOTTE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AO
Authorized Official - Prefix:
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-661-5425
Mailing Address - Street 1:4535 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33980-2930
Mailing Address - Country:US
Mailing Address - Phone:941-625-2667
Mailing Address - Fax:941-315-9922
Practice Address - Street 1:4535 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-2930
Practice Address - Country:US
Practice Address - Phone:941-625-2667
Practice Address - Fax:941-315-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-12
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center