=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932557766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LAUNCH PAD WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2016
-----------------------------------------------------
Last Update Date | 06/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1105 MERCHANT LN
-----------------------------------------------------
City | CAROLINA BEACH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28428-4716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-769-6053
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3121 WRIGHTSVILLE AVE
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE
-----------------------------------------------------
Name | LORALIE GRIGAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-769-9048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------