MEDICARE: AUTHENTIC INTEGRATIVE WELLNESS INC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1922563634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTHENTIC INTEGRATIVE WELLNESS INC

Provider Business Mailing Address
First Line	:	2003 W CYPRESS CREEK RD STE 103
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-1834
Country	:	US
Telephone Number	:	954-616-5246
Fax Number	:	754-701-6433

Provider Business Practice Location Address
First Line	:	2003 W CYPRESS CREEK RD STE 103
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-1834
Country	:	US
Telephone Number	:	954-616-5246
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. JESSICA VERA
Credential	:	PHD
Telephone Number	:	954-616-5246

Provider Enumeration Date	:	02/06/2019
Last Update Date	:	03/20/2019

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