MEDICARE: SPINAL CONNECTIONS WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QP3300X	Pain Clinic/Center
2	261QR0800X	Recovery Care Clinic/Center
3	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1295610020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINAL CONNECTIONS WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	1118 SANDALWOOD CIR
Second Line	:
City	:	NICEVILLE
State	:	FL
Zip	:	32578-4213
Country	:	US
Telephone Number	:	951-505-7600
Fax Number	:	951-505-7600

Provider Business Practice Location Address
First Line	:	415 MOUNTAIN DR
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-7327
Country	:	US
Telephone Number	:	951-505-7600
Fax Number	:

Authorized Official
Title or Position	:	MASSAGE THERAPIST
Name	:	KLEIDY BOTICH
Credential	:
Telephone Number	:	951-505-7600

Provider Enumeration Date	:	08/11/2025
Last Update Date	:	08/11/2025

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