Healthcare Provider Details

I. General information

NPI: 1043734106
Provider Name (Legal Business Name): NEW LIFE HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 A1A N STE 105
PONTE VEDRA BEACH FL
32082-4098
US

IV. Provider business mailing address

1102 A1A N STE 105
PONTE VEDRA BEACH FL
32082-4098
US

V. Phone/Fax

Practice location:
  • Phone: 904-763-9707
  • Fax:
Mailing address:
  • Phone: 904-763-9707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH12247
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME73574
License Number StateFL

VIII. Authorized Official

Name: DR. SEAN CURTIS TRACY
Title or Position: CHIROPRACTIC PHYSICIAN, CEO
Credential: DC
Phone: 904-763-9707