Provider Demographics
NPI:1780081273
Name:SEABROOK ISLAND WELLNESS INCORPORATED
Entity type:Organization
Organization Name:SEABROOK ISLAND WELLNESS INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITE KURYLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-940-3828
Mailing Address - Street 1:3020 S FLORIDA AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-4053
Mailing Address - Country:US
Mailing Address - Phone:863-940-3828
Mailing Address - Fax:
Practice Address - Street 1:3020 S FLORIDA AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4053
Practice Address - Country:US
Practice Address - Phone:863-940-3828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEABROOK ISLAND WELLNESS INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM73933251E00000X, 251S00000X, 305R00000X, 302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No305R00000XManaged Care OrganizationsPreferred Provider Organization