Basic Information
| Provider Information | |||||||||
| NPI: | 1821491168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAIN COMPLETE WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1868 HIGHLAND OAKS BLVD STE B | ||||||||
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| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335597413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135742460 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10311 CROSS CREEK BLVD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336472989 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139079898 | ||||||||
| FaxNumber: | 8139070220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2014 | ||||||||
| LastUpdateDate: | 10/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | WITT | ||||||||
| AuthorizedOfficialFirstName: | SUSANNE | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8135742460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.