Healthcare Provider Details

I. General information

NPI: 1437798139
Provider Name (Legal Business Name): FAMILY WELLNESS AND AESTHETIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2019
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 W OAKLAND PARK BLVD STE B105
SUNRISE FL
33351-6741
US

IV. Provider business mailing address

7800 W OAKLAND PARK BLVD STE B105
SUNRISE FL
33351-6741
US

V. Phone/Fax

Practice location:
  • Phone: 954-890-3902
  • Fax: 954-999-0230
Mailing address:
  • Phone: 954-890-3892
  • Fax: 954-999-0230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: FANUEL DORILAS
Title or Position: PRESIDENT
Credential:
Phone: 954-478-2041