Healthcare Provider Details

I. General information

NPI: 1295610020
Provider Name (Legal Business Name): SPINAL CONNECTIONS WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/11/2025
Certification Date: 08/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MOUNTAIN DR
DESTIN FL
32541-7327
US

IV. Provider business mailing address

1118 SANDALWOOD CIR
NICEVILLE FL
32578-4213
US

V. Phone/Fax

Practice location:
  • Phone: 951-505-7600
  • Fax:
Mailing address:
  • Phone: 951-505-7600
  • Fax: 951-505-7600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KLEIDY BOTICH
Title or Position: MASSAGE THERAPIST
Credential:
Phone: 951-505-7600