MEDICARE: WAKE LYMPHEDEMA AND WELLNESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1174106793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WAKE LYMPHEDEMA AND WELLNESS

Provider Business Mailing Address
First Line	:	5713 ENOREE LN
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-5773
Country	:	US
Telephone Number	:	330-760-4375
Fax Number	:

Provider Business Practice Location Address
First Line	:	5713 ENOREE LN
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-5773
Country	:	US
Telephone Number	:	330-760-4375
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER/OWNER
Name	:	COLLEEN M COX
Credential	:	DPT
Telephone Number	:	330-760-4375

Provider Enumeration Date	:	05/02/2021
Last Update Date	:	05/02/2021

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