Healthcare Provider Details

I. General information

NPI: 1548709926
Provider Name (Legal Business Name): LASER THERAPY HEALTH AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E HALLANDALE BEACH BLVD SUITE 15
HALLANDALE BEACH FL
33009-4477
US

IV. Provider business mailing address

800 E HALLANDALE BEACH BLVD SUITE 15
HALLANDALE BEACH FL
33009-4477
US

V. Phone/Fax

Practice location:
  • Phone: 954-455-8400
  • Fax: 954-455-0300
Mailing address:
  • Phone: 954-455-8400
  • Fax: 954-455-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number2114
License Number StateFL

VIII. Authorized Official

Name: RANDI GOLD
Title or Position: BUSINESS OWNER
Credential: V.P/CFO
Phone: 954-455-8400