Healthcare Provider Details

I. General information

NPI: 1730631037
Provider Name (Legal Business Name): MILLENNIUM WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N FEDERAL HWY 104
HALLANDALE BEACH FL
33009-4300
US

IV. Provider business mailing address

110 N FEDERAL HWY 104
HALLANDALE BEACH FL
33009-4300
US

V. Phone/Fax

Practice location:
  • Phone: 305-417-0006
  • Fax:
Mailing address:
  • Phone: 305-417-0006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY 8220
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9104275
License Number StateFL

VIII. Authorized Official

Name: ZHANNA ZITSBANK
Title or Position: MEMBER
Credential: PA-C
Phone: 305-417-0006