Healthcare Provider Details

I. General information

NPI: 1013147834
Provider Name (Legal Business Name): WC WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 SW 3RD ST SUITE 2270
POMPANO BEACH FL
33060-6932
US

IV. Provider business mailing address

600 SW 3RD ST SUITE 2270
POMPANO BEACH FL
33060-6932
US

V. Phone/Fax

Practice location:
  • Phone: 954-241-0303
  • Fax:
Mailing address:
  • Phone: 954-241-0303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME63070
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP1348922
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP2053552
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP2876402
License Number StateFL

VIII. Authorized Official

Name: MR. PHIL DETOURNILLON
Title or Position: TREASURER
Credential:
Phone: 954-241-0303