Provider Demographics
NPI:1992558621
Name:MODERN WELLNESS LLC
Entity type:Organization
Organization Name:MODERN WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, IADN CERT
Authorized Official - Phone:352-346-2461
Mailing Address - Street 1:1251 CANDLELIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3009
Mailing Address - Country:US
Mailing Address - Phone:352-346-2461
Mailing Address - Fax:
Practice Address - Street 1:1251 CANDLELIGHT BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3009
Practice Address - Country:US
Practice Address - Phone:352-346-2461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty