Provider Demographics
NPI:1861733628
Name:BACK TO BASIC WELLNESS SERVICES LLC
Entity type:Organization
Organization Name:BACK TO BASIC WELLNESS SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:VELEZ-MAYMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-761-4388
Mailing Address - Street 1:15757 PINES BLVD
Mailing Address - Street 2:SUITE 295
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1207
Mailing Address - Country:US
Mailing Address - Phone:305-761-4388
Mailing Address - Fax:
Practice Address - Street 1:15757 PINES BLVD
Practice Address - Street 2:SUITE 295
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1207
Practice Address - Country:US
Practice Address - Phone:305-761-4388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care