=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861129587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROCARE WELLNESS NETWORK INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2022
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 EISENHOWER DR BLDG 500
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31406-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-348-3818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340 EISENHOWER DR BLDG 500
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31406-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-348-3818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC OWNER
-----------------------------------------------------
Name | DOMENICK PISCIOTTA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-315-4732
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------