=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902544851
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORE ESSENTIALS PHYSICAL THERAPY & WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2022
-----------------------------------------------------
Last Update Date | 08/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 472 OSCEOLA AVE
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-4082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-734-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 472 OSCEOLA AVE
-----------------------------------------------------
City | JACKSONVILLE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32250-4082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-734-1697
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JESSICA GROCHOWSKY
-----------------------------------------------------
Credential | PT, DPT, MTC, CLT
-----------------------------------------------------
Telephone | 386-801-1683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------