Healthcare Provider Details

I. General information

NPI: 1992825145
Provider Name (Legal Business Name): INTERNAL MEDICINE & PEDIATRICS WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6038 W. NORDLING LOOP
CRYSTAL RIVER FL
34429
US

IV. Provider business mailing address

PO BOX 2012
LECANTO FL
34460
US

V. Phone/Fax

Practice location:
  • Phone: 352-795-2459
  • Fax: 352-795-4322
Mailing address:
  • Phone: 352-795-2459
  • Fax: 352-795-4322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME93743
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME93743
License Number StateFL

VIII. Authorized Official

Name: MRS. CARLENE A. WILSON
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 352-795-2459