=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093380057
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STAY WELL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2021
-----------------------------------------------------
Last Update Date | 01/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6295 LAKE WORTH RD STE 40
-----------------------------------------------------
City | GREENACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33463-3034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-704-1275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3898 VIA POINCIANA STE 15
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33467-2951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-308-0818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | YORDANY MARTINEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-704-1275
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------