=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114376969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENATURA WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2016
-----------------------------------------------------
Last Update Date | 06/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 BRICKELL AVE SUITE 1460
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33131-3067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-302-6359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66 VALENCIA AVE APT. 1103
-----------------------------------------------------
City | CORAL GABLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33134-6101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-302-6359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. TEBA ORUETA
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 305-302-6359
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA67631
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------