=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760075162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS & RECOVERY PSYCHIATRY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2021
-----------------------------------------------------
Last Update Date | 02/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3430 NW 97TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33147-2237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-597-7426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3430 NW 97TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33147-2237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-597-7426
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APRN
-----------------------------------------------------
Name | MARLON MEDINA
-----------------------------------------------------
Credential | PMHNP-BC
-----------------------------------------------------
Telephone | 786-597-7426
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------