=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801452446
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URBANA WELLNESS ONLINE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2019
-----------------------------------------------------
Last Update Date | 05/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7510 PINEVILLE MATTHEWS RD STE 5B
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28226-4076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-706-0101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1105 BERWICK CT
-----------------------------------------------------
City | WAXHAW
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28173-6547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-840-7644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MAURICE LEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-840-7644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------