MEDICARE: SEABROOK ISLAND WELLNESS INCORPORATED

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	251E00000X	Home Health Agency	M73933	FL
2	251S00000X	Community/Behavioral Health Agency	M73933	FL
3	305R00000X	Preferred Provider Organization	M73933	FL
4	302F00000X	Exclusive Provider Organization	M73933	FL

General Provider Information

NPI Number	:	1780081273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEABROOK ISLAND WELLNESS INCORPORATED

Provider Business Mailing Address
First Line	:	3020 S FLORIDA AVE
Second Line	:	SUITE 207
City	:	LAKELAND
State	:	FL
Zip	:	33803-4053
Country	:	US
Telephone Number	:	863-940-3828
Fax Number	:

Provider Business Practice Location Address
First Line	:	3020 S FLORIDA AVE
Second Line	:	SUITE 207
City	:	LAKELAND
State	:	FL
Zip	:	33803-4053
Country	:	US
Telephone Number	:	863-940-3828
Fax Number	:

Authorized Official
Title or Position	:	PROPRIETOR
Name	:	MS. MARY E WHITE KURYLA
Credential	:
Telephone Number	:	863-940-3828

Provider Enumeration Date	:	11/26/2014
Last Update Date	:	11/26/2014

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