Healthcare Provider Details

I. General information

NPI: 1306246319
Provider Name (Legal Business Name): DEYARD WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2014
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 DUNLAWTON AVE STE 2
PORT ORANGE FL
32127-2922
US

IV. Provider business mailing address

1728 DUNLAWTON AVE STE 2
PORT ORANGE FL
32127-2922
US

V. Phone/Fax

Practice location:
  • Phone: 386-322-3505
  • Fax: 386-322-3509
Mailing address:
  • Phone: 386-322-3505
  • Fax: 386-322-3509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberME68224
License Number StateFL

VIII. Authorized Official

Name: LAURA YARD
Title or Position: VP
Credential: MD
Phone: 386-322-3505