Provider Demographics
NPI:1578371860
Name:MIDIWELL
Entity type:Organization
Organization Name:MIDIWELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TELICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:904-534-4279
Mailing Address - Street 1:806 LAUREL VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-2708
Mailing Address - Country:US
Mailing Address - Phone:866-884-9646
Mailing Address - Fax:
Practice Address - Street 1:806 LAUREL VALLEY DR
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-2708
Practice Address - Country:US
Practice Address - Phone:866-884-9646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care