MEDICARE: DEYARD WELLNESS CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	ME68224	FL

General Provider Information

NPI Number	:	1306246319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEYARD WELLNESS CENTER

Provider Business Mailing Address
First Line	:	1728 DUNLAWTON AVE
Second Line	:	STE 2
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2922
Country	:	US
Telephone Number	:	386-322-3505
Fax Number	:	386-322-3509

Provider Business Practice Location Address
First Line	:	1728 DUNLAWTON AVE
Second Line	:	STE 2
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2922
Country	:	US
Telephone Number	:	386-322-3505
Fax Number	:	386-322-3509

Authorized Official
Title or Position	:	VP
Name	:	LAURA YARD
Credential	:	MD
Telephone Number	:	386-322-3505

Provider Enumeration Date	:	08/27/2014
Last Update Date	:	08/27/2014

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Directions to “DEYARD WELLNESS CENTER ” Practice Location

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