=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083434559
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIZEN WELLNESS LOUNGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2024
-----------------------------------------------------
Last Update Date | 12/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1081 TOWN CENTER DR STE 200
-----------------------------------------------------
City | ORANGE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32763-8360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-218-0764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1081 TOWN CENTER DR STE 200
-----------------------------------------------------
City | ORANGE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32763-8360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-218-0764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ATIA GIPSON
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 386-218-0764
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------