=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174789150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHT WORKS WELLNESS CENTRE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2008
-----------------------------------------------------
Last Update Date | 07/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4601 E HIGHWAY 100 SUITE B-8
-----------------------------------------------------
City | BUNNELL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32110-9017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-437-5992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4601 E HIGHWAY 100 SUITE B-8
-----------------------------------------------------
City | BUNNELL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32110-9017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-437-5992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | MS. CAROLYN J RANDOLPH
-----------------------------------------------------
Credential | L.M.T.
-----------------------------------------------------
Telephone | 386-931-2212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | MM12805
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------