=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114441532
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINETIC WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7707 FANNIN ST STE 154
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054-1918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-727-5056
-----------------------------------------------------
Fax | 713-501-8933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7707 FANNIN ST STE 154
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77054-1918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-727-5056
-----------------------------------------------------
Fax | 713-501-8933
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/MANAGER
-----------------------------------------------------
Name | SEBASTIAN CALVO
-----------------------------------------------------
Credential | CMA
-----------------------------------------------------
Telephone | 832-727-5056
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------