=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033368329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS WISE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2008
-----------------------------------------------------
Last Update Date | 09/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 W MIDWAY RD
-----------------------------------------------------
City | FORT PIERCE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34982-4142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-812-9953
-----------------------------------------------------
Fax | 772-871-7842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6800 NW MONOCO CT
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-5376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-812-9953
-----------------------------------------------------
Fax | 772-871-7842
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | TRINA WISE HENKEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-812-9953
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA37838
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------