Provider Demographics
NPI:1922426402
Name:INTENTIONALLY WELL, LLC
Entity Type:Organization
Organization Name:INTENTIONALLY WELL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER, CEO
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:PINDER
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:772-215-9946
Mailing Address - Street 1:3716 SW MOORE ST
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-5647
Mailing Address - Country:US
Mailing Address - Phone:772-215-9946
Mailing Address - Fax:
Practice Address - Street 1:3716 SW MOORE ST
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-5647
Practice Address - Country:US
Practice Address - Phone:772-215-9946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69414207Q00000X
FL1476272363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1912256538OtherNPI