=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932390598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRUNSWICK HOLISTIC THERAPY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2007
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 618 N HOWE ST
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28461-3426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-454-0404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 618 N HOWE ST
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28461-3426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARYBETH WEINACHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-454-0404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 6655
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------