Healthcare Provider Details

I. General information

NPI: 1265676902
Provider Name (Legal Business Name): SPA SARASOTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 EDGEWOOD AVE S SUITE 5
JACKSONVILLE FL
32205-0810
US

IV. Provider business mailing address

1147 EDGEWOOD AVE S SUITE 5
JACKSONVILLE FL
32205-0810
US

V. Phone/Fax

Practice location:
  • Phone: 904-738-0369
  • Fax:
Mailing address:
  • Phone: 904-738-0369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberMM21136
License Number StateZZ

VIII. Authorized Official

Name: MR. JEAN-PAUL H. D'ANGELO
Title or Position: OWNER
Credential: L.M.T.
Phone: 904-738-0369