Healthcare Provider Details

I. General information

NPI: 1245410125
Provider Name (Legal Business Name): CORTEZ WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 59TH ST W
BRADENTON FL
34209-7017
US

IV. Provider business mailing address

2215 59TH ST W
BRADENTON FL
34209-7017
US

V. Phone/Fax

Practice location:
  • Phone: 941-753-0006
  • Fax: 941-761-7224
Mailing address:
  • Phone: 941-753-0006
  • Fax: 941-761-7224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberCH0003890
License Number StateFL

VIII. Authorized Official

Name: MS. MARILYN E LAVIGNE
Title or Position: CHIROPRACTOR
Credential:
Phone: 941-753-0006