Healthcare Provider Details

I. General information

NPI: 1982255865
Provider Name (Legal Business Name): ROOTS 2 WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LEE RD STE F
WINTER PARK FL
32789-1862
US

IV. Provider business mailing address

PO BOX 1101
WINTER PARK FL
32790-1101
US

V. Phone/Fax

Practice location:
  • Phone: 407-756-3005
  • Fax:
Mailing address:
  • Phone: 407-756-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN ERIC MAINIT
Title or Position: OWNER/PRACTICE MANAGER
Credential:
Phone: 407-756-3005