Provider Demographics
NPI:1831569359
Name:WELL-WATERED GARDEN MASSAGE AND WELLNESS
Entity type:Organization
Organization Name:WELL-WATERED GARDEN MASSAGE AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:BRACERO
Authorized Official - Suffix:
Authorized Official - Credentials:MT, NHD
Authorized Official - Phone:386-717-6720
Mailing Address - Street 1:502 N SPRING GARDEN AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3193
Mailing Address - Country:US
Mailing Address - Phone:386-740-0006
Mailing Address - Fax:
Practice Address - Street 1:502 N SPRING GARDEN AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3193
Practice Address - Country:US
Practice Address - Phone:386-740-0006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-26
Last Update Date:2015-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM32743225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty