Healthcare Provider Details

I. General information

NPI: 1912449976
Provider Name (Legal Business Name): W4P LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 11/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17240 CORTEZ BLVD
BROOKSVILLE FL
34601-8921
US

IV. Provider business mailing address

PO BOX 9188
DAYTONA BEACH FL
32120-9188
US

V. Phone/Fax

Practice location:
  • Phone: 352-796-5111
  • Fax: 386-274-7801
Mailing address:
  • Phone: 386-274-7800
  • Fax: 386-274-7801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RODERICK N BENNETT
Title or Position: PRESIDENT
Credential: MD
Phone: 386-274-7914