Healthcare Provider Details

I. General information

NPI: 1033885603
Provider Name (Legal Business Name): SOULSHINE HOLISTIC WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5922 GOLETA CIR
MELBOURNE FL
32940-8035
US

IV. Provider business mailing address

5922 GOLETA CIR
MELBOURNE FL
32940-8035
US

V. Phone/Fax

Practice location:
  • Phone: 321-266-1427
  • Fax: 888-727-0593
Mailing address:
  • Phone: 321-266-1427
  • Fax: 888-727-0593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: AMBER DICKSON
Title or Position: OWNER
Credential:
Phone: 321-266-1427