MEDICARE: ELEVATE FUNCTIONAL WELLNESS AND PRIMARY CARE, INC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1720899032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATE FUNCTIONAL WELLNESS AND PRIMARY CARE, INC

Provider Business Mailing Address
First Line	:	868 SHORELINE CIR
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-2741
Country	:	US
Telephone Number	:	904-866-9551
Fax Number	:

Provider Business Practice Location Address
First Line	:	868 SHORELINE CIR
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-2741
Country	:	US
Telephone Number	:	904-866-9551
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	AMY L GROBSTICK
Credential	:	APRN
Telephone Number	:	904-866-9551

Provider Enumeration Date	:	01/16/2025
Last Update Date	:	01/16/2025

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