MEDICARE: INTERNATIONAL WUDANG INTERNAL MARTIAL ARTS RESEARCH ASSOCIATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12456	OTHER		SAYS OPTIONAL BUT SEEMS REQUIRED

General Provider Information

NPI Number	:	1235735325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERNATIONAL WUDANG INTERNAL MARTIAL ARTS RESEARCH ASSOCIATION

Provider Business Mailing Address
First Line	:	430 N PINE MEADOW DR
Second Line	:
City	:	DEBARY
State	:	FL
Zip	:	32713-2306
Country	:	US
Telephone Number	:	386-753-0897
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 N PINE MEADOW DR
Second Line	:
City	:	DEBARY
State	:	FL
Zip	:	32713-2306
Country	:	US
Telephone Number	:	386-753-0897
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MS. THERESA M MORGAN
Credential	:
Telephone Number	:	386-753-0897

Provider Enumeration Date	:	12/05/2020
Last Update Date	:	04/15/2021

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