Provider Demographics
NPI:1053811968
Name:WELLISTICS CONDITIONING CENTER INC
Entity type:Organization
Organization Name:WELLISTICS CONDITIONING CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRISELDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-994-2243
Mailing Address - Street 1:133 JANE LN
Mailing Address - Street 2:
Mailing Address - City:SAINT ROSE
Mailing Address - State:LA
Mailing Address - Zip Code:70087-3218
Mailing Address - Country:US
Mailing Address - Phone:504-224-2400
Mailing Address - Fax:
Practice Address - Street 1:7392 NW 35TH TER # 209-210
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33122-1271
Practice Address - Country:US
Practice Address - Phone:786-650-0060
Practice Address - Fax:786-536-2503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
FL302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherMEDICINE DOCTOR
FL=========OtherCHIROPRACTOR