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General NPI Number Information
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NPI Number | 1710152897
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Entity Type | Organization
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Legal Business Name | ST. JOHNS WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 04/29/2008
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Last Update Date | 04/29/2008
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Provider Practice Location Address
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Address Line | 305 KINGSLEY LAKE DR SUITE 702
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City | ST AUGUSTINE
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State | FL
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Zip | 32092-3043
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Country | US
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Telephone | 904-537-0674
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Fax |
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Provider Business Mailing Address
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Address Line | 4361 COMANCHE TRAIL BLVD
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City | SAINT JOHNS
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State | FL
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Zip | 32259-4285
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Country | US
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Telephone | 904-537-0674
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. DARLENE L. TORROLL
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Credential | LMT
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Telephone | 904-537-0674
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MM18687
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License Number State | FL
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