Provider Demographics
NPI:1043633795
Name:BREVARD WELLNESS CLINC 1 LLC
Entity type:Organization
Organization Name:BREVARD WELLNESS CLINC 1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVAS
Authorized Official - Middle Name:RAO
Authorized Official - Last Name:DONTINENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-751-9506
Mailing Address - Street 1:1264 MALABAR RD SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2556
Mailing Address - Country:US
Mailing Address - Phone:321-751-9506
Mailing Address - Fax:321-751-9505
Practice Address - Street 1:1264 MALABAR RD SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2556
Practice Address - Country:US
Practice Address - Phone:321-751-9506
Practice Address - Fax:321-751-9505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88036207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty