MEDICARE: THE LAUNCH PAD WELLNESS, LLC

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1932557766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE LAUNCH PAD WELLNESS, LLC

Provider Business Mailing Address
First Line	:	3121 WRIGHTSVILLE AVE
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-4111
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1105 MERCHANT LN
Second Line	:
City	:	CAROLINA BEACH
State	:	NC
Zip	:	28428-4716
Country	:	US
Telephone Number	:	910-769-6053
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATIVE
Name	:	LORALIE GRIGAS
Credential	:
Telephone Number	:	919-769-9048

Provider Enumeration Date	:	06/02/2016
Last Update Date	:	06/02/2016

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