MEDICARE: PLANT CITY WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1215187372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLANT CITY WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	2005 W REYNOLDS ST
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-4743
Country	:	US
Telephone Number	:	813-754-6700
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 W REYNOLDS ST
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-4743
Country	:	US
Telephone Number	:	813-754-6700
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SUSAN BINGHAM
Credential	:
Telephone Number	:	813-754-6700

Provider Enumeration Date	:	09/25/2008
Last Update Date	:	01/07/2009

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