Provider Demographics
NPI:1699909168
Name:HEALTH & WELLNESS CENTER OF PORT ST LUCIE INC
Entity type:Organization
Organization Name:HEALTH & WELLNESS CENTER OF PORT ST LUCIE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIEMBA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-337-3141
Mailing Address - Street 1:433 NW PRIMA VISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8731
Mailing Address - Country:US
Mailing Address - Phone:772-337-3141
Mailing Address - Fax:772-336-1160
Practice Address - Street 1:433 NW PRIMA VISTA BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8731
Practice Address - Country:US
Practice Address - Phone:772-337-3141
Practice Address - Fax:772-336-1160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006248111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3803511-00Medicaid
FLU17808Medicare UPIN
FL3803511-00Medicaid