Provider Demographics
NPI:1487239539
Name:BRD WELLNESS PLLC
Entity type:Organization
Organization Name:BRD WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BAMBI
Authorized Official - Middle Name:
Authorized Official - Last Name:DENAIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-613-4125
Mailing Address - Street 1:613 POWELL DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-2038
Mailing Address - Country:US
Mailing Address - Phone:337-278-4107
Mailing Address - Fax:
Practice Address - Street 1:60 2ND ST UNIT C-7
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1769
Practice Address - Country:US
Practice Address - Phone:850-613-4125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center