MEDICARE: DIGNIFIED 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	261QP2300X	Primary Care Clinic/Center

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	:	1578269932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIGNIFIED WELLNESS LLC

Provider Business Mailing Address
First Line	:	5851 TIMUQUANA RD STE 104
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-7890
Country	:	US
Telephone Number	:	904-553-1139
Fax Number	:

Provider Business Practice Location Address
First Line	:	5851 TIMUQUANA RD STE 104
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-7890
Country	:	US
Telephone Number	:	904-553-1139
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	VICTORIA UDONGWO
Credential	:	NP
Telephone Number	:	904-553-1139

Provider Enumeration Date	:	02/06/2023
Last Update Date	:	02/06/2023

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Directions to “DIGNIFIED WELLNESS LLC ” Practice Location

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