Healthcare Provider Details

I. General information

NPI: 1699366385
Provider Name (Legal Business Name): WELLQUEST LIFESTYLE REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E ROBERTSON ST
BRANDON FL
33511-5253
US

IV. Provider business mailing address

110 MITCHELL DR
BRANDON FL
33511-6831
US

V. Phone/Fax

Practice location:
  • Phone: 813-404-6006
  • Fax:
Mailing address:
  • Phone: 813-404-6006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: CAMILLE CLARK
Title or Position: MEDICAL BILLING ASSOCIATE
Credential:
Phone: 754-205-6154