Provider Demographics
NPI:1154698686
Name:IBEJI WELLNESS THERAPY
Entity type:Organization
Organization Name:IBEJI WELLNESS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-274-8883
Mailing Address - Street 1:9835 SW 72ND ST
Mailing Address - Street 2:STE 204
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-4670
Mailing Address - Country:US
Mailing Address - Phone:305-274-8883
Mailing Address - Fax:305-274-8885
Practice Address - Street 1:9835 SW 72ND ST
Practice Address - Street 2:STE 204
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-4670
Practice Address - Country:US
Practice Address - Phone:305-274-8883
Practice Address - Fax:305-274-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC9554261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy