Healthcare Provider Details

I. General information

NPI: 1104130129
Provider Name (Legal Business Name): SPECTRUM WELLCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1298 MINNESOTA AVE STE A
WINTER PARK FL
32789-7104
US

IV. Provider business mailing address

13201 LAKE CLARICE DR
WINDERMERE FL
34786-7405
US

V. Phone/Fax

Practice location:
  • Phone: 407-615-4102
  • Fax:
Mailing address:
  • Phone: 407-615-4102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP 2734
License Number StateFL

VIII. Authorized Official

Name: MR. AJAY PUROHIT
Title or Position: PRESIDENT
Credential: AP
Phone: 407-615-4102