Healthcare Provider Details

I. General information

NPI: 1124815873
Provider Name (Legal Business Name): BALSAM BOSOM WELLNESS AND RESTORATIVE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10930 US HIGHWAY 231
WETUMPKA AL
36092-5115
US

IV. Provider business mailing address

10930 US HIGHWAY 231
WETUMPKA AL
36092-5115
US

V. Phone/Fax

Practice location:
  • Phone: 334-478-3168
  • Fax:
Mailing address:
  • Phone: 334-478-3168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License Number
License Number State

VIII. Authorized Official

Name: JULIA M. KLINE-FUENTES
Title or Position: FOUNDER
Credential:
Phone: 334-478-3168