Healthcare Provider Details

I. General information

NPI: 1063207967
Provider Name (Legal Business Name): SUNSHINE STATE WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SHOTGUN RD
SUNRISE FL
33326-1903
US

IV. Provider business mailing address

2828 S SEACREST BLVD STE 213A
BOYNTON BEACH FL
33435-7944
US

V. Phone/Fax

Practice location:
  • Phone: 561-501-2391
  • Fax:
Mailing address:
  • Phone: 561-501-2391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENT MCNEAL
Title or Position: PRES
Credential:
Phone: 561-501-2391