Healthcare Provider Details

I. General information

NPI: 1861954653
Provider Name (Legal Business Name): FAMILY WELLNESS CENTER GCS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3189 HIGHWAY 17
GREEN COVE SPRINGS FL
32043-9371
US

IV. Provider business mailing address

3189 HIGHWAY 17
GREEN COVE SPRINGS FL
32043-9371
US

V. Phone/Fax

Practice location:
  • Phone: 904-621-0247
  • Fax:
Mailing address:
  • Phone: 904-621-0247
  • Fax: 904-339-9945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RANDALL SCOTT
Title or Position: OWNER
Credential: DO
Phone: 904-621-0247