Healthcare Provider Details

I. General information

NPI: 1770722936
Provider Name (Legal Business Name): MEDICAL AND WELLNESS CENTER OF MELROSE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 SR 100
MELROSE FL
32666
US

IV. Provider business mailing address

1745 SR 100
MELROSE FL
32666
US

V. Phone/Fax

Practice location:
  • Phone: 954-854-4290
  • Fax:
Mailing address:
  • Phone: 352-478-2471
  • Fax: 352-478-2496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberACN205
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberARNP780412
License Number StateFL

VIII. Authorized Official

Name: MS. KENYETTA LATRICE REESE
Title or Position: PRESIDENT/CEO
Credential:
Phone: 352-478-2471