=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407554033
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONQUER PHYSIO WELLNESS & TRAINING SYSTEMS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2023
-----------------------------------------------------
Last Update Date | 07/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15045 MICHELANGELO BLVD BLDG APT 201
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33446-2899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-443-9365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15045 MICHELANGELO BLVD APT 201
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33446-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SAMNTHA KERSHEN
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 989-443-9365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------