Provider Demographics
NPI:1053034298
Name:HEAVEN WELLNESS MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:HEAVEN WELLNESS MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAZARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HURTADO HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-409-9457
Mailing Address - Street 1:PO BOX 15542
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33684-5542
Mailing Address - Country:US
Mailing Address - Phone:813-415-2891
Mailing Address - Fax:813-443-3149
Practice Address - Street 1:11961 N FLORIDA AVE STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5213
Practice Address - Country:US
Practice Address - Phone:813-415-2891
Practice Address - Fax:813-443-3149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation