MEDICARE: SPA LONGEVITA ACUPUNCTURE & HERBAL MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171100000X	Acupuncturist	AP2936	FL

General Provider Information

NPI Number	:	1144698713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPA LONGEVITA ACUPUNCTURE & HERBAL MEDICINE

Provider Business Mailing Address
First Line	:	3730 AVALON PARK BLVD E # 8
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-4805
Country	:	US
Telephone Number	:	407-440-3990
Fax Number	:

Provider Business Practice Location Address
First Line	:	3730 AVALON PARK BLVD E # 8
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-4805
Country	:	US
Telephone Number	:	407-440-3990
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. BROOKE E HIGGINIS
Credential	:	DO
Telephone Number	:	440-440-3990

Provider Enumeration Date	:	09/12/2015
Last Update Date	:	09/12/2015

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