Healthcare Provider Details

I. General information

NPI: 1982203634
Provider Name (Legal Business Name): CENTRAL FLORIDA WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15516 W COLONIAL DR STE 111
WINTER GARDEN FL
34787-9558
US

IV. Provider business mailing address

8081 TURKEY LAKE RD STE 650
ORLANDO FL
32819-7321
US

V. Phone/Fax

Practice location:
  • Phone: 407-226-2993
  • Fax: 407-226-2996
Mailing address:
  • Phone: 407-226-2993
  • Fax: 407-226-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN T SHORTLY
Title or Position: OWNER
Credential:
Phone: 863-559-3434