NPIMap

Organization Active NPI

Brevard Wellness Clinc 1 LLC

  • Internal Medicine Physician
  • Palm Bay, FL
National Provider Identifier
1043633795
Registry record updated Jan 31, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
ME88036 Issued in FL
Legal business name
BREVARD WELLNESS CLINC 1 LLC
Practice address
1264 Malabar Rd SE
Palm Bay, FL 32907-2556
Phone
(321) 751-9506
Fax
(321) 751-9505
NPI assigned
Jan 31, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 31, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Srinivas Rao Dontineni, M.D.
Title
President
Phone
(321) 751-9506

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207R00000X ME88036 FL Primary

Addresses

Primary practice location

1264 Malabar Rd SE
Palm Bay, FL 32907-2556

Mailing address

1264 Malabar Rd SE
Palm Bay, FL 32907-2556
Phone (321) 751-9506

National Provider Directory

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1391126400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1391126400000",
    "number": "1043633795",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1264 MALABAR RD SE",
            "city": "PALM BAY",
            "state": "FL",
            "postal_code": "329072556",
            "telephone_number": "321-751-9506",
            "fax_number": "321-751-9505"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1264 MALABAR RD SE",
            "city": "PALM BAY",
            "state": "FL",
            "postal_code": "329072556",
            "telephone_number": "321-751-9506",
            "fax_number": "321-751-9505"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREVARD WELLNESS CLINC 1 LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-01-31",
        "last_updated": "2014-01-31",
        "status": "A",
        "authorized_official_last_name": "DONTINENI",
        "authorized_official_first_name": "SRINIVAS",
        "authorized_official_middle_name": "RAO",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "321-751-9506",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine",
            "state": "FL",
            "license": "ME88036",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Palm Bay, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 31, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.