Provider Demographics
NPI:1992825145
Name:INTERNAL MEDICINE & PEDIATRICS WELLNESS CENTER
Entity type:Organization
Organization Name:INTERNAL MEDICINE & PEDIATRICS WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-795-2459
Mailing Address - Street 1:PO BOX 2012
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34460
Mailing Address - Country:US
Mailing Address - Phone:352-795-2459
Mailing Address - Fax:352-795-4322
Practice Address - Street 1:6038 W. NORDLING LOOP
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429
Practice Address - Country:US
Practice Address - Phone:352-795-2459
Practice Address - Fax:352-795-4322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93743207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI17924Medicare UPIN
FLK9178Medicare PIN