MEDICARE: NEW IDENTITY WELLNESS CENTER 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	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558984971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW IDENTITY WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	14601 SW 29TH ST STE 107
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33027-4715
Country	:	US
Telephone Number	:	954-589-1971
Fax Number	:	305-317-4453

Provider Business Practice Location Address
First Line	:	14601 SW 29TH ST STE 107
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33027-4715
Country	:	US
Telephone Number	:	786-804-9405
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	CARIDAD HAYES
Credential	:
Telephone Number	:	954-589-1971

Provider Enumeration Date	:	05/20/2020
Last Update Date	:	10/09/2025

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Directions to “NEW IDENTITY WELLNESS CENTER LLC ” Practice Location

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