Provider Demographics
NPI:1528305018
Name:AFFINITY WELLNESS CORPORATIONS
Entity type:Organization
Organization Name:AFFINITY WELLNESS CORPORATIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-732-1007
Mailing Address - Street 1:2211 S HIGHWAY 77
Mailing Address - Street 2:SUITE 101-102
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-4640
Mailing Address - Country:US
Mailing Address - Phone:850-896-1818
Mailing Address - Fax:850-722-8782
Practice Address - Street 1:2211 S HIGHWAY 77
Practice Address - Street 2:SUITE 101-102
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-4640
Practice Address - Country:US
Practice Address - Phone:850-896-1818
Practice Address - Fax:850-722-8782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty