Healthcare Provider Details

I. General information

NPI: 1477790988
Provider Name (Legal Business Name): GINA BETH BUSHELON DOM, A.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2009
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 DUNLAWTON AVE STE 3
PORT ORANGE FL
32127-9284
US

IV. Provider business mailing address

808 DUNLAWTON AVE STE 3
PORT ORANGE FL
32127-9284
US

V. Phone/Fax

Practice location:
  • Phone: 386-767-7366
  • Fax: 386-200-6263
Mailing address:
  • Phone: 386-767-7366
  • Fax: 386-200-6263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP2623
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: