Provider Demographics
NPI:1508347261
Name:FIT FOR SERVICE WELLNESS
Entity Type:Organization
Organization Name:FIT FOR SERVICE WELLNESS
Other - Org Name:BRACANE COMPANY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:214-335-1234
Mailing Address - Street 1:1201 E 15TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-6238
Mailing Address - Country:US
Mailing Address - Phone:469-814-0658
Mailing Address - Fax:972-727-6239
Practice Address - Street 1:1201 E 15TH ST STE 204
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-6238
Practice Address - Country:US
Practice Address - Phone:469-814-0658
Practice Address - Fax:972-727-6239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3715955Medicaid
TX3715963Medicaid