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General NPI Number Information
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NPI Number | 1013147834
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Entity Type | Organization
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Legal Business Name | WC WELLNESS LLC
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Dates
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Enumeration Date | 07/15/2009
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Last Update Date | 07/15/2009
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Provider Practice Location Address
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Address Line | 600 SW 3RD ST SUITE 2270
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City | POMPANO BEACH
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State | FL
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Zip | 33060-6932
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Country | US
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Telephone | 954-241-0303
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Fax |
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Provider Business Mailing Address
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Address Line | 600 SW 3RD ST SUITE 2270
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City | POMPANO BEACH
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State | FL
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Zip | 33060-6932
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Country | US
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Telephone | 954-241-0303
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Fax |
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Authorized Official
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Title or Position | TREASURER
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Name | MR. PHIL DETOURNILLON
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Credential |
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Telephone | 954-241-0303
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | ARNP1348922
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | ARNP2053552
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | ARNP2876402
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | ME63070
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License Number State | FL
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