Healthcare Provider Details

I. General information

NPI: 1053733956
Provider Name (Legal Business Name): SW FLORIDA WELLNESS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2014
Last Update Date: 01/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27499 RIVERVIEW CENTER BLVD SUITE 115
BONITA SPRINGS FL
34134-4313
US

IV. Provider business mailing address

215 TOPANGA DR
BONITA SPRINGS FL
34134-8545
US

V. Phone/Fax

Practice location:
  • Phone: 239-216-6556
  • Fax:
Mailing address:
  • Phone: 239-216-6556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND5698
License Number StateFL

VIII. Authorized Official

Name: MICHELE LICAUSI-SILANO
Title or Position: PRESIDENT
Credential: MA, MS, RD, LDM, RYT
Phone: 201-693-2224