=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306603238
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MBS WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2024
-----------------------------------------------------
Last Update Date | 03/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1002 N MITTHOEFER RD STE A
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46229-2461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-985-4885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1002 N MITTHOEFER RD STE A
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46229-2461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-985-4885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | BROOKE D RATCLIFFE
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 317-985-4885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------