MEDICARE: PALMETTO LAKES WELLNESS CENTER 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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1942694070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMETTO LAKES WELLNESS CENTER INC

Provider Business Mailing Address
First Line	:	5190 NW 167TH ST STE 102
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-6329
Country	:	US
Telephone Number	:	786-955-6598
Fax Number	:	786-955-6857

Provider Business Practice Location Address
First Line	:	5190 NW 167TH ST STE 102
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-6329
Country	:	US
Telephone Number	:	786-955-6598
Fax Number	:	786-955-6857

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANNIA RODRIGUEZ
Credential	:
Telephone Number	:	786-955-6598

Provider Enumeration Date	:	03/26/2015
Last Update Date	:	03/26/2015

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