Healthcare Provider Details

I. General information

NPI: 1932848801
Provider Name (Legal Business Name): ST. CHARLES WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 NE 8TH ST STE 109
HOMESTEAD FL
33030-4734
US

IV. Provider business mailing address

311 NE 8TH ST STE 109
HOMESTEAD FL
33030-4734
US

V. Phone/Fax

Practice location:
  • Phone: 305-363-5573
  • Fax: 786-622-1893
Mailing address:
  • Phone: 305-363-5573
  • Fax: 786-622-1893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROSITA ATILUS
Title or Position: PROVIDER
Credential: DNP, APRN, FNP-BC
Phone: 786-259-2966