MEDICARE: ILQ WLLENESS

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1437526530
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILQ WLLENESS

Provider Business Mailing Address
First Line	:	8201 PETERS RD
Second Line	:	C/O MPG
City	:	PLANTATION
State	:	FL
Zip	:	33324-3265
Country	:	US
Telephone Number	:	786-520-5274
Fax Number	:

Provider Business Practice Location Address
First Line	:	8201 PETERS RD
Second Line	:	C/O MPG
City	:	PLANTATION
State	:	FL
Zip	:	33324-3265
Country	:	US
Telephone Number	:	786-520-5274
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RONDA ROGERS
Credential	:
Telephone Number	:	786-520-5274

Provider Enumeration Date	:	08/25/2015
Last Update Date	:	08/25/2015

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