Healthcare Provider Details

I. General information

NPI: 1336792894
Provider Name (Legal Business Name): TAMPA BAY HOLISTIC WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 N MARION ST
TAMPA FL
33602-2638
US

IV. Provider business mailing address

1607 N MARION ST
TAMPA FL
33602-2638
US

V. Phone/Fax

Practice location:
  • Phone: 813-513-4248
  • Fax: 813-513-3903
Mailing address:
  • Phone: 813-513-4248
  • Fax: 813-513-3903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State

VIII. Authorized Official

Name: MS. DAWN ANN MOLINA
Title or Position: OWNER
Credential: DOM
Phone: 813-513-4248