Provider Demographics
NPI:1992239917
Name:DELRAY BEACH WELLNESS CENTER LLC
Entity type:Organization
Organization Name:DELRAY BEACH WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-203-3584
Mailing Address - Street 1:1300 NW 17TH AVE
Mailing Address - Street 2:SUITE 145
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-2578
Mailing Address - Country:US
Mailing Address - Phone:844-763-9968
Mailing Address - Fax:877-281-1665
Practice Address - Street 1:1300 NW 17TH AVE
Practice Address - Street 2:SUITE 145
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-2578
Practice Address - Country:US
Practice Address - Phone:844-763-9968
Practice Address - Fax:877-281-1665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty