Provider Demographics
NPI:1265629745
Name:ABSOLUTE WELLNESS CENTER
Entity Type:Organization
Organization Name:ABSOLUTE WELLNESS CENTER
Other - Org Name:KEVAN D. KRUSE, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINETTE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-654-5413
Mailing Address - Street 1:641 W LUMSDEN RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5911
Mailing Address - Country:US
Mailing Address - Phone:813-654-5413
Mailing Address - Fax:813-643-1457
Practice Address - Street 1:641 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5911
Practice Address - Country:US
Practice Address - Phone:813-654-5413
Practice Address - Fax:813-643-1457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6698111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8865Medicare PIN