Healthcare Provider Details

I. General information

NPI: 1871819870
Provider Name (Legal Business Name): WELLNESS WORX CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2495 ENTERPRISE RD STE104
CLEARWATER FL
33763-1795
US

IV. Provider business mailing address

2495 ENTERPRISE RD STE104
CLEARWATER FL
33763-1795
US

V. Phone/Fax

Practice location:
  • Phone: 727-474-9729
  • Fax: 727-474-9947
Mailing address:
  • Phone: 727-474-9729
  • Fax: 727-474-9947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH8772
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH8923
License Number StateFL

VIII. Authorized Official

Name: DR. GLEN CHARLES PETTERSEN
Title or Position: OWNER
Credential: DC
Phone: 727-474-9729