MEDICARE: ATLANTIS INTEGRATIVE MEDICINE AND PSYCHIATRY WELLNESS CENTER PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1720764020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIS INTEGRATIVE MEDICINE AND PSYCHIATRY WELLNESS CENTER PLLC

Provider Business Mailing Address
First Line	:	2194 HIGHWAY A1A STE 203
Second Line	:
City	:	INDIAN HARBOUR BEACH
State	:	FL
Zip	:	32937-4931
Country	:	US
Telephone Number	:	833-867-2329
Fax Number	:	833-867-3757

Provider Business Practice Location Address
First Line	:	2194 HIGHWAY A1A STE 203
Second Line	:
City	:	INDIAN HARBOUR BEACH
State	:	FL
Zip	:	32937-4931
Country	:	US
Telephone Number	:	833-867-2329
Fax Number	:	833-867-3757

Authorized Official
Title or Position	:	BUSINESS OFFICE ADVOCATE
Name	:	MS. THI HOANG
Credential	:
Telephone Number	:	702-205-8232

Provider Enumeration Date	:	06/22/2023
Last Update Date	:	06/22/2023

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