Healthcare Provider Details

I. General information

NPI: 1659826345
Provider Name (Legal Business Name): WELLNESS GROUP OF SOUTH FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SE LONITA ST
STUART FL
34994-3447
US

IV. Provider business mailing address

104 SE LONITA ST
STUART FL
34994-3447
US

V. Phone/Fax

Practice location:
  • Phone: 772-463-2344
  • Fax: 442-463-9565
Mailing address:
  • Phone: 772-463-2344
  • Fax: 442-463-9565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: DR. CHARLES A SIMPSON
Title or Position: PRESIDENT
Credential: DC
Phone: 772-463-2344