=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104130129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM WELLCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2010
-----------------------------------------------------
Last Update Date | 08/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1298 MINNESOTA AVE STE A
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-7104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-615-4102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13201 LAKE CLARICE DR
-----------------------------------------------------
City | WINDERMERE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34786-7405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-615-4102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. AJAY PUROHIT
-----------------------------------------------------
Credential | AP
-----------------------------------------------------
Telephone | 407-615-4102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP 2734
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------