Basic Information
| Provider Information | |||||||||
| NPI: | 1134495245 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHSTAT WELLNESS-POLK HAINES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HEALTHSTAT ON-SITE CLINIC/POLK COUNTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 CHARLOTTE PARK DR | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282171915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045296161 | ||||||||
| FaxNumber: | 7049365570 | ||||||||
| Practice Location | |||||||||
| Address1: | 631B US HIGHWAY 17 92 W | ||||||||
| Address2: | |||||||||
| City: | HAINES CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338445047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635193858 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2012 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | PATTON | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | JOHNSON | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF RISK MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 7049365546 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 2083P0500X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5709730 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER |