=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861713661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENDIPITY HEALTH & WELLNESS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2010
-----------------------------------------------------
Last Update Date | 03/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4011 W PLANO PKWY STE 100
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-801-0741
-----------------------------------------------------
Fax | 888-972-1621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4011 W PLANO PKWY STE 100
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-801-0741
-----------------------------------------------------
Fax | 888-972-1621
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. AMY GRADDY ST. JOHN
-----------------------------------------------------
Credential | DC, LMT
-----------------------------------------------------
Telephone | 214-801-0741
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT028852
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 11054
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------