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General NPI Number Information
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NPI Number | 1639351570
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Entity Type | Organization
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Legal Business Name | PHYSICIANS WELLNESS ASSOCIATES
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Dates
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Enumeration Date | 12/03/2007
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Last Update Date | 12/03/2007
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Provider Practice Location Address
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Address Line | 2251 GRAND AVE
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City | FORT MYERS
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State | FL
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Zip | 33901-3742
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Country | US
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Telephone | 239-337-2273
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Fax |
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Provider Business Mailing Address
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Address Line | 2251 GRAND AVE
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City | FORT MYERS
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State | FL
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Zip | 33901-3742
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | PIERRE A. GASTON
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Credential | M.D.
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Telephone | 239-337-2273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH8566
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME41852
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License Number State | FL
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