Healthcare Provider Details

I. General information

NPI: 1386188159
Provider Name (Legal Business Name): MR. WIDMARK ROY DWYER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 UNICORN CT
PALM COAST FL
32164-5760
US

IV. Provider business mailing address

22 UNICORN CT
PALM COAST FL
32164-5760
US

V. Phone/Fax

Practice location:
  • Phone: 561-692-1925
  • Fax:
Mailing address:
  • Phone: 561-692-1925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberT520553726280
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: