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General NPI Number Information
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NPI Number | 1043636822
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Entity Type | Organization
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Legal Business Name | JACKSONVILLE WELLNESS CENTER & PREVENTIVE MEDICINE CLINIC
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Dates
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Enumeration Date | 03/17/2014
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Last Update Date | 03/17/2014
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Provider Practice Location Address
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Address Line | 3604 UNIVERSITY BLVD S
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City | JACKSONVILLE
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State | FL
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Zip | 32216-4241
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Country | US
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Telephone | 904-563-5838
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Fax | 904-425-7889
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Provider Business Mailing Address
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Address Line | 2317 BLANDING BLVD SUITE 2
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City | JACKSONVILLE
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State | FL
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Zip | 32210-4194
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Country | US
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Telephone | 904-388-7968
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Fax | 904-425-7889
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | DIANA M CORDERO
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Credential | M.D.
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Telephone | 904-388-7968
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME57227
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License Number State | FL
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