Provider Demographics
NPI:1073892188
Name:WILD GRACE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:WILD GRACE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ESTES
Authorized Official - Suffix:
Authorized Official - Credentials:LPTA, LMT
Authorized Official - Phone:207-737-2478
Mailing Address - Street 1:36 LUDWIG RD
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04342-3411
Mailing Address - Country:US
Mailing Address - Phone:207-737-2478
Mailing Address - Fax:
Practice Address - Street 1:36 LUDWIG RD
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:ME
Practice Address - Zip Code:04342-3411
Practice Address - Country:US
Practice Address - Phone:207-737-2478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-07
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT29422251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty