| Organization Name: | WILD GRACE WELLNESS CENTER LLC |
| NPI Number: | 1073892188 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | EMILY ANN ESTES (OWNER) |
| Mailing Address: | 36 Ludwig Rd Dresden |
| State: | ME US |
| Postal Code: | 043423411 |
| Phone Number: | 2077372478 |
| Fax Number: | |
| NPI Enumeration Date: | 08/07/2011 |
| NPI Last Update Date: | 08/07/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 2251X0800X |
| License Number: | PT2942 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ME |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | Orthopedic |
| Taxonomy Definition: | |