Provider Demographics
NPI:1679396279
Name:PHOENIX WELLNESS CENTER LLC
Entity type:Organization
Organization Name:PHOENIX WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-830-0212
Mailing Address - Street 1:13356 SW 128TH ST STE 4
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-5807
Mailing Address - Country:US
Mailing Address - Phone:786-830-0212
Mailing Address - Fax:
Practice Address - Street 1:13356 SW 128TH ST STE 4
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5807
Practice Address - Country:US
Practice Address - Phone:786-830-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health