=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073906665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSTITUTE 4 WELLNESS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2015
-----------------------------------------------------
Last Update Date | 03/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 SE 168TH CT
-----------------------------------------------------
City | SILVER SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34488-5473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-482-8179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2234 N FEDERAL HWY # 297
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33431-7710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-482-8179
-----------------------------------------------------
Fax | 954-776-7884
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | DR. MARK ROSSELI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-482-8179
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------