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General NPI Number Information
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NPI Number | 1538706288
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Entity Type | Organization
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Legal Business Name | BLUEWATER WELLNESS GROUP LLC
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Dates
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Enumeration Date | 12/02/2019
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Last Update Date | 12/02/2019
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Provider Practice Location Address
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Address Line | 4400 E HIGHWAY 20 STE 207
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City | NICEVILLE
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State | FL
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Zip | 32578-7700
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Country | US
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Telephone | 850-897-1177
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Fax |
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Provider Business Mailing Address
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Address Line | 4854 ORLIMAR ST
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City | CRESTVIEW
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State | FL
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Zip | 32536-6413
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIROPRACTOR/ OWNER
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Name | LETITIA SMITH
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Credential |
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Telephone | 757-329-7145
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NP0017X
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Taxonomy Name | Pediatric Chiropractor
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License Number |
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License Number State |
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