Basic Information
| Provider Information | |||||||||
| NPI: | 1376889519 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAIN COMPLETE WELLNESS LLC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAIN COMPLETE WELLNESS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1868 HIGHLAND OAKS BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335597413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135742460 | ||||||||
| FaxNumber: | 8139495001 | ||||||||
| Practice Location | |||||||||
| Address1: | 2901 BUSCH LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336141860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139367979 | ||||||||
| FaxNumber: | 8139361600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2012 | ||||||||
| LastUpdateDate: | 09/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | BAIN | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | F. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8139079898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | CH8562 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 225100000X | PT20198 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207Q00000X | ME115880 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.