Healthcare Provider Details

I. General information

NPI: 1710850326
Provider Name (Legal Business Name): WILLIEMAE MIND & BODY INC DBA STRETCHLAB FIRST COAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 A1A BEACH BLVD
ST AUGUSTINE FL
32080-6732
US

IV. Provider business mailing address

3601 FLAMINGO ST
ST AUGUSTINE FL
32080-9114
US

V. Phone/Fax

Practice location:
  • Phone: 904-490-9242
  • Fax:
Mailing address:
  • Phone: 904-490-8766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: DAVID RAMOS
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 904-490-8766