Provider Demographics
NPI:1447544747
Name:PRIMARY WELLNESS CENTER
Entity type:Organization
Organization Name:PRIMARY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:305-982-8471
Mailing Address - Street 1:6445 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-4813
Mailing Address - Country:US
Mailing Address - Phone:305-982-8471
Mailing Address - Fax:305-982-8572
Practice Address - Street 1:6445 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:WEST MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-4813
Practice Address - Country:US
Practice Address - Phone:305-982-8471
Practice Address - Fax:305-982-8572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC9174208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC9174OtherAHCA CERTIFICATION