MEDICARE: GREEN WAVE FAMILY WELLNESS CENTER

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	101YM0800X	Mental Health Counselor	MH-6603	FL
2	106H00000X	Marriage & Family Therapist	MT-0001678	FL
3	111N00000X	Chiropractor	CH 8571	FL

General Provider Information

NPI Number	:	1568662864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN WAVE FAMILY WELLNESS CENTER

Provider Business Mailing Address
First Line	:	215 FOREST PARK CIR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4916
Country	:	US
Telephone Number	:	850-215-5657
Fax Number	:	850-215-5658

Provider Business Practice Location Address
First Line	:	215 FOREST PARK CIR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4916
Country	:	US
Telephone Number	:	850-215-5657
Fax Number	:	850-215-5658

Authorized Official
Title or Position	:	MANAGING OFFICER
Name	:	JOHN C CLUXTON
Credential	:	PH.D.
Telephone Number	:	850-215-5657

Provider Enumeration Date	:	07/24/2007
Last Update Date	:	07/24/2007

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