=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194681650
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIRVANA WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2025
-----------------------------------------------------
Last Update Date | 12/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2598 E SUNRISE BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33304-3230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-648-2134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2598 E SUNRISE BLVD
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33304-3230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-648-2134
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | PATRICIA CROCANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-696-6105
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------