Provider Demographics
NPI:1518798214
Name:ILLUSIONS WELLNESS AND RECOVERY LLC
Entity type:Organization
Organization Name:ILLUSIONS WELLNESS AND RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NYDIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHITAKER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:723-577-6323
Mailing Address - Street 1:800 VIGINIA AVE
Mailing Address - Street 2:STE 59 B
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982
Mailing Address - Country:US
Mailing Address - Phone:772-577-6323
Mailing Address - Fax:
Practice Address - Street 1:800 VIGINIA AVE
Practice Address - Street 2:STE 59 B
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982
Practice Address - Country:US
Practice Address - Phone:772-577-6323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-13
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health