Healthcare Provider Details

I. General information

NPI: 1497440846
Provider Name (Legal Business Name): GO SPA WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 JAMES CIR
LAKE ALFRED FL
33850-2753
US

IV. Provider business mailing address

341 JAMES CIR
LAKE ALFRED FL
33850-2753
US

V. Phone/Fax

Practice location:
  • Phone: 863-449-0929
  • Fax:
Mailing address:
  • Phone: 863-449-0929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: LORAINE GORDON
Title or Position: OWNER/MASSAGE THERAPIST
Credential:
Phone: 863-449-0929