Healthcare Provider Details

I. General information

NPI: 1861232423
Provider Name (Legal Business Name): SHINE AYG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N FEDERAL HWY
BOCA RATON FL
33432-2737
US

IV. Provider business mailing address

815 N FEDERAL HWY
BOCA RATON FL
33432-2737
US

V. Phone/Fax

Practice location:
  • Phone: 561-409-4854
  • Fax:
Mailing address:
  • Phone: 561-409-4854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANDREA BEATRIZ PENA CASTILLO SR.
Title or Position: OWNER
Credential:
Phone: 786-660-3711