Provider Demographics
NPI:1275425803
Name:WELLNESSCLINIC ON WHEELS LLC
Entity type:Organization
Organization Name:WELLNESSCLINIC ON WHEELS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EL AGATHE
Authorized Official - Middle Name:ASOPO
Authorized Official - Last Name:TANYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-834-7722
Mailing Address - Street 1:1747 FORT SMITH BLVD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32725-3728
Mailing Address - Country:US
Mailing Address - Phone:202-834-7722
Mailing Address - Fax:
Practice Address - Street 1:470 S SPRING GARDEN AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-5080
Practice Address - Country:US
Practice Address - Phone:202-834-7722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty