=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932843992
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR WELLNESS CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2022
-----------------------------------------------------
Last Update Date | 07/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5258 LINTON BLVD STE 105
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33484-6564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-292-3436
-----------------------------------------------------
Fax | 561-292-3479
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5258 LINTON BLVD STE 105
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33484-6564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-292-3436
-----------------------------------------------------
Fax | 561-292-3479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HENRI PHILIUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-554-0280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------