Provider Demographics
NPI:1821491168
Name:BAIN COMPLETE WELLNESS LLC
Entity Type:Organization
Organization Name:BAIN COMPLETE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:F
Authorized Official - Last Name:WITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-574-2460
Mailing Address - Street 1:1868 HIGHLAND OAKS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-7413
Mailing Address - Country:US
Mailing Address - Phone:813-574-2460
Mailing Address - Fax:
Practice Address - Street 1:10311 CROSS CREEK BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2989
Practice Address - Country:US
Practice Address - Phone:813-907-9898
Practice Address - Fax:813-907-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty