Healthcare Provider Details

I. General information

NPI: 1144770686
Provider Name (Legal Business Name): THE PALMS WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10570 S US HIGHWAY 1 SUITE 102
PORT SAINT LUCIE FL
34952-5606
US

IV. Provider business mailing address

10570 S US HIGHWAY 1 SUITE 102
PORT SAINT LUCIE FL
34952-5606
US

V. Phone/Fax

Practice location:
  • Phone: 772-828-6992
  • Fax:
Mailing address:
  • Phone: 772-828-6992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberME83014
License Number StateFL

VIII. Authorized Official

Name: MRS. BETH IRIS HERNANDEZ
Title or Position: CEO
Credential:
Phone: 772-828-6992