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General NPI Number Information
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NPI Number | 1275008716
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Entity Type | Organization
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Legal Business Name | CENTRAL FLORIDA WELLNESS LLC
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Dates
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Enumeration Date | 10/11/2018
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Last Update Date | 10/11/2018
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Provider Practice Location Address
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Address Line | 1800 W HIBISCUS BLVD STE 131
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City | MELBOURNE
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State | FL
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Zip | 32901-2633
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Country | US
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Telephone | 407-226-2993
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Fax | 407-226-2996
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Provider Business Mailing Address
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Address Line | 7932 W SAND LAKE RD
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City | ORLANDO
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State | FL
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Zip | 32819-7263
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Country | US
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Telephone | 407-226-2993
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Fax | 407-226-2996
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Authorized Official
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Title or Position | OWNER
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Name | TIM SHORTLEY
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Credential |
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Telephone | 407-226-2993
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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