Healthcare Provider Details

I. General information

NPI: 1710152897
Provider Name (Legal Business Name): ST. JOHNS WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 KINGSLEY LAKE DR SUITE 702
ST AUGUSTINE FL
32092-3043
US

IV. Provider business mailing address

4361 COMANCHE TRAIL BLVD
SAINT JOHNS FL
32259-4285
US

V. Phone/Fax

Practice location:
  • Phone: 904-537-0674
  • Fax:
Mailing address:
  • Phone: 904-537-0674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMM18687
License Number StateFL

VIII. Authorized Official

Name: MS. DARLENE L. TORROLL
Title or Position: OWNER
Credential: LMT
Phone: 904-537-0674