Healthcare Provider Details

I. General information

NPI: 1114880069
Provider Name (Legal Business Name): WELLNESS RANCH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 STONEY POINT ROAD
FRANKLIN KY
42134-6726
US

IV. Provider business mailing address

621 NW 53RD ST STE 370
BOCA RATON FL
33487-8241
US

V. Phone/Fax

Practice location:
  • Phone: 978-440-3200
  • Fax: 323-529-8134
Mailing address:
  • Phone:
  • Fax: 978-440-3200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. NICHOLAS PETRILLO
Title or Position: CEO
Credential:
Phone: 978-440-3200