MEDICARE: GROTTO MEDCLUB 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	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1598081416	OTHER	FL	NPPES

General Provider Information

NPI Number	:	1821505215
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROTTO MEDCLUB LLC

Provider Business Mailing Address
First Line	:	224 DATURA ST STE 315
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-5631
Country	:	US
Telephone Number	:	561-214-3323
Fax Number	:

Provider Business Practice Location Address
First Line	:	224 DATURA ST STE 315
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-5631
Country	:	US
Telephone Number	:	561-214-3323
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE MANAGER/CO-OWNER
Name	:	ZAQUERI WAYNE WILSON
Credential	:
Telephone Number	:	561-214-3323

Provider Enumeration Date	:	01/07/2018
Last Update Date	:	01/07/2018

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Directions to “GROTTO MEDCLUB LLC ” Practice Location

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