Provider Demographics
NPI:1962962316
Name:SOUTHEAST WELLNESS LANE CORP
Entity type:Organization
Organization Name:SOUTHEAST WELLNESS LANE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YURI
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAS ESPINOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-493-2293
Mailing Address - Street 1:13265 SW 39TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-4748
Mailing Address - Country:US
Mailing Address - Phone:786-493-2293
Mailing Address - Fax:
Practice Address - Street 1:13265 SW 39TH ST
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-4748
Practice Address - Country:US
Practice Address - Phone:786-493-2293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006456700Medicaid