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General NPI Number Information
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NPI Number | 1619303740
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Entity Type | Organization
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Legal Business Name | BAIN COMPLETE WELLNESS LLC
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Dates
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Enumeration Date | 09/20/2013
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Last Update Date | 07/28/2014
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Provider Practice Location Address
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Address Line | 2901 BUSCH LAKE BLVD
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City | TAMPA
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State | FL
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Zip | 33614-1860
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Country | US
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Telephone | 813-936-7979
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Fax |
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Provider Business Mailing Address
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Address Line | 10323 CROSS CREEK BLVD STE E
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City | TAMPA
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State | FL
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Zip | 33647-2988
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Country | US
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Telephone | 813-907-9898
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | SUSANNE WITT
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Credential |
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Telephone | 813-907-9898
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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