Healthcare Provider Details

I. General information

NPI: 1598047698
Provider Name (Legal Business Name): ADVANCED HEALTHCARE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9114 TOWN CENTER PKWY STE 101
LAKEWOOD RANCH FL
34202-5053
US

IV. Provider business mailing address

9114 TOWN CENTER PKWY STE 101
LAKEWOOD RANCH FL
34202-5054
US

V. Phone/Fax

Practice location:
  • Phone: 941-351-4949
  • Fax: 941-351-3033
Mailing address:
  • Phone: 941-351-4949
  • Fax: 941-351-3033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberAP2931
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP2931
License Number StateFL

VIII. Authorized Official

Name: MR. MARIO DUBE
Title or Position: MEMBER
Credential: D.O.M.
Phone: 941-351-4949