MEDICARE: WELLNESSCLINIC ON WHEELS

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750046363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLNESSCLINIC ON WHEELS

Provider Business Mailing Address
First Line	:	1747 FORT SMITH BLVD
Second Line	:
City	:	DELTONA
State	:	FL
Zip	:	32725-3728
Country	:	US
Telephone Number	:	202-834-7722
Fax Number	:

Provider Business Practice Location Address
First Line	:	1747 FORT SMITH BLVD
Second Line	:
City	:	DELTONA
State	:	FL
Zip	:	32725-3728
Country	:	US
Telephone Number	:	202-834-7722
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EL AGATHE ASOPO TEMBENG
Credential	:	APRN
Telephone Number	:	202-834-7722

Provider Enumeration Date	:	11/08/2021
Last Update Date	:	09/09/2022

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Directions to “WELLNESSCLINIC ON WHEELS ” Practice Location

Language	Start Address	Practice Location

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