=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205168697
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTENTIONAL WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2010
-----------------------------------------------------
Last Update Date | 02/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2139 W STATE ROAD 434 UNIT 101
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32779-5019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-774-7744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2139 W STATE ROAD 434 UNIT 101
-----------------------------------------------------
City | LONGWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32779-5019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-774-7744
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER/OWNER
-----------------------------------------------------
Name | MRS. ROBYN JENNIFER ROSE
-----------------------------------------------------
Credential | MPT,CST-D
-----------------------------------------------------
Telephone | 407-774-7744
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT18020
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------