Healthcare Provider Details

I. General information

NPI: 1306260161
Provider Name (Legal Business Name): BWELL REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2014
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 COMMERCIAL CT STE A
VENICE FL
34292-1653
US

IV. Provider business mailing address

405 COMMERCIAL CT STE A
VENICE FL
34292-1653
US

V. Phone/Fax

Practice location:
  • Phone: 941-484-9291
  • Fax:
Mailing address:
  • Phone: 718-640-7917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ6600
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: KARINA VISHNEVSKY
Title or Position: PRESIDENT
Credential: SLP
Phone: 941-484-9291