=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821467846
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ABSOLUTE WELLNESS & PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2015
-----------------------------------------------------
Last Update Date | 10/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 OLEVIA ST APT 239
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-3485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-573-3265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1900 OLEVIA ST APT 239
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32207-3485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-573-3265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | WANDA VERNEE ROLAND
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 773-573-3265
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------