Provider Demographics
NPI:1053733956
Name:SW FLORIDA WELLNESS CORP
Entity type:Organization
Organization Name:SW FLORIDA WELLNESS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:LICAUSI-SILANO
Authorized Official - Suffix:
Authorized Official - Credentials:MA, MS, RD, LDM, RYT
Authorized Official - Phone:201-693-2224
Mailing Address - Street 1:215 TOPANGA DR
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-8545
Mailing Address - Country:US
Mailing Address - Phone:239-216-6556
Mailing Address - Fax:
Practice Address - Street 1:27499 RIVERVIEW CENTER BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4313
Practice Address - Country:US
Practice Address - Phone:239-216-6556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-11
Last Update Date:2014-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5698133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty