Healthcare Provider Details

I. General information

NPI: 1760928063
Provider Name (Legal Business Name): PHYSICIANS WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 PALM IS NW
CLEARWATER BEACH FL
33767-1934
US

IV. Provider business mailing address

228 PALM IS NW
CLEARWATER BEACH FL
33767-1934
US

V. Phone/Fax

Practice location:
  • Phone: 513-266-6226
  • Fax: 513-887-7512
Mailing address:
  • Phone: 513-266-6226
  • Fax: 513-887-7512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES MICHAEL POPA III
Title or Position: OWNER
Credential: D.C.
Phone: 513-266-6226