Healthcare Provider Details

I. General information

NPI: 1861073157
Provider Name (Legal Business Name): KEW WELLNESS CENTER 2, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6333 LANGSTON AVE
NEW PORT RICHEY FL
34653-1014
US

IV. Provider business mailing address

1793 EAGLE CREST DR
FLEMING ISLAND FL
32003-4521
US

V. Phone/Fax

Practice location:
  • Phone: 727-846-8487
  • Fax: 888-736-5589
Mailing address:
  • Phone: 904-386-6636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE WILGER
Title or Position: PRESIDENT
Credential:
Phone: 904-386-6636