Provider Demographics
NPI:1053187179
Name:MEDIWELL LLC
Entity type:Organization
Organization Name:MEDIWELL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:HERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-346-4709
Mailing Address - Street 1:1742 S WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-7915
Mailing Address - Country:US
Mailing Address - Phone:646-346-4709
Mailing Address - Fax:
Practice Address - Street 1:921 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8311
Practice Address - Country:US
Practice Address - Phone:646-346-4709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty