Provider Demographics
NPI:1437661873
Name:ROBERT WEDGEWORTH, LLC
Entity type:Organization
Organization Name:ROBERT WEDGEWORTH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEDGEWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-717-7425
Mailing Address - Street 1:2766 SIXMA RD
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32738-9575
Mailing Address - Country:US
Mailing Address - Phone:386-717-7425
Mailing Address - Fax:386-789-1666
Practice Address - Street 1:2744 HOWLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELTONA
Practice Address - State:FL
Practice Address - Zip Code:32725-9617
Practice Address - Country:US
Practice Address - Phone:386-717-7425
Practice Address - Fax:386-789-1666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care