Organization
GROTTO MEDCLUB LLC
Active
Other names
MedClub by Dr. Jenn
Organization subpart
No
Provider details
NPI number
Authorized official
ZAQUERI WAYNE WILSON (PRACTICE MANAGER/CO-OWNER)
(561) 214-3323
Entity
Organization
Contact information
Practice address
224 DATURA ST STE 315, WEST PALM BEACH, FL 33401-5631
(561) 214-3323
Mailing address
224 DATURA ST STE 315, WEST PALM BEACH, FL 33401-5631
(561) 214-3323
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1598081416
NPPES
FL
Enumeration date
01/07/2018
Last updated
01/07/2018
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