| Southeast Wellness Lane Corp | |
|
13265 Sw 39th St Davie FL 33330-4748 | |
| (786) 493-2293 | |
| Not Available |
| Full Name | Southeast Wellness Lane Corp |
|---|---|
| Speciality | Internal Medicine |
| Location | 13265 Sw 39th St, Davie, Florida |
| Authorized Official Name and Position | Yuri Salas Espinosa (PRESIDENT) |
| Authorized Official Contact | 7864932293 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southeast Wellness Lane Corp 13265 Sw 39th St Davie FL 33330-4748 Ph: (786) 493-2293 | Southeast Wellness Lane Corp 13265 Sw 39th St Davie FL 33330-4748 Ph: (786) 493-2293 |
| NPI Number | 1962962316 |
|---|---|
| Provider Enumeration Date | 03/21/2019 |
| Last Update Date | 03/21/2019 |
| Medicare PECOS PAC ID | 8820329642 |
|---|---|
| Medicare Enrollment ID | O20191009001920 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1962962316 | NPI | - | NPPES |
| 006456700 | Medicaid | FL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Primary |
| Provider Name | Yuri Salas Espinosa |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1679843494 PECOS PAC ID: 1658520168 Enrollment ID: I20120926000839 |
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