MEDICARE: MINDFUL EYE WELLNESS LLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1497407480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL EYE WELLNESS LLC

Provider Business Mailing Address
First Line	:	1080 SW FENWAY RD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-2303
Country	:	US
Telephone Number	:	561-313-2807
Fax Number	:

Provider Business Practice Location Address
First Line	:	1645 PALM BEACH LAKES BLVD STE 440
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-2217
Country	:	US
Telephone Number	:	561-463-4200
Fax Number	:	561-469-0720

Authorized Official
Title or Position	:	APRN
Name	:	MRS. SUSAN LYNCH PHILCOX
Credential	:	APRN, PMHNP-BC
Telephone Number	:	561-313-2807

Provider Enumeration Date	:	01/21/2022
Last Update Date	:	03/15/2022

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