Provider Demographics
NPI:1053615179
Name:WELLSPRING MEDICAL CENTER LLC
Entity type:Organization
Organization Name:WELLSPRING MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:PRICE
Authorized Official - Last Name:HUNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-254-6803
Mailing Address - Street 1:21 SUNTREE PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-7600
Mailing Address - Country:US
Mailing Address - Phone:321-254-6803
Mailing Address - Fax:321-254-6819
Practice Address - Street 1:21 SUNTREE PL
Practice Address - Street 2:SUITE 101
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-7600
Practice Address - Country:US
Practice Address - Phone:321-254-6803
Practice Address - Fax:321-254-6819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95892261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care