Healthcare Provider Details

I. General information

NPI: 1851702740
Provider Name (Legal Business Name): LIVING WELL ACUPUNCTURE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3653 CORTEZ RD W STE 120
BRADENTON FL
34210-3168
US

IV. Provider business mailing address

3653 CORTEZ RD W STE 120
BRADENTON FL
34210-3168
US

V. Phone/Fax

Practice location:
  • Phone: 941-301-6940
  • Fax:
Mailing address:
  • Phone: 941-301-6940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number3445
License Number StateFL

VIII. Authorized Official

Name: DR. REYNA Q BRAGG
Title or Position: DOM AP
Credential: DOM AP
Phone: 941-301-6940