=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992209878
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED MOVEMENT & WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2018
-----------------------------------------------------
Last Update Date | 03/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 W 2ND ST
-----------------------------------------------------
City | WINNEMUCCA
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89445-3406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-795-9502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 996
-----------------------------------------------------
City | WINNEMUCCA
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89446-0996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-795-9502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | MADISON ELIZABETH GRAY JENSEN
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 636-795-9502
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 3436
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------