Healthcare Provider Details

I. General information

NPI: 1437661873
Provider Name (Legal Business Name): ROBERT WEDGEWORTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2744 HOWLAND BLVD
DELTONA FL
32725-9617
US

IV. Provider business mailing address

2766 SIXMA RD
DELTONA FL
32738-9575
US

V. Phone/Fax

Practice location:
  • Phone: 386-717-7425
  • Fax: 386-789-1666
Mailing address:
  • Phone: 386-717-7425
  • Fax: 386-789-1666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DIANE WEDGEWORTH
Title or Position: OWNER
Credential:
Phone: 386-717-7425