Provider Demographics
NPI:1619521267
Name:SPACE TO BE WELL, LLC
Entity Type:Organization
Organization Name:SPACE TO BE WELL, LLC
Other - Org Name:INTEGRATIVE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRAMONTES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:612-405-4478
Mailing Address - Street 1:PO BOX 7324
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-0324
Mailing Address - Country:US
Mailing Address - Phone:715-808-2480
Mailing Address - Fax:
Practice Address - Street 1:1091 SUTHERLAND AVE
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-7509
Practice Address - Country:US
Practice Address - Phone:651-447-8907
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-31
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty