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General NPI Number Information
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NPI Number | 1154723823
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Entity Type | Organization
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Legal Business Name | DATE WELLNESS CENTER INC
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Dates
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Enumeration Date | 09/24/2014
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Last Update Date | 09/24/2014
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Provider Practice Location Address
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Address Line | 5190 NW 167TH ST STE 308
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City | MIAMI LAKES
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State | FL
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Zip | 33014-6328
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Country | US
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Telephone | 305-974-5683
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Fax | 305-646-1361
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Provider Business Mailing Address
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Address Line | 5190 NW 167TH ST STE 308
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City | MIAMI LAKES
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State | FL
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Zip | 33014-6328
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Country | US
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Telephone | 305-974-5683
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Fax | 305-646-1361
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. JESSICA KELNER
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Credential | MD
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Telephone | 305-974-5683
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | OS12303
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License Number State | FL
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