Healthcare Provider Details

I. General information

NPI: 1033397302
Provider Name (Legal Business Name): STUART S. SHIPE, D.O.M., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 02/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 SE HILLMOOR DR SUITE A104
PORT ST LUCIE FL
34952-7553
US

IV. Provider business mailing address

1801 SE HILLMOOR DR SUITE A104
PORT ST LUCIE FL
34952-7553
US

V. Phone/Fax

Practice location:
  • Phone: 772-398-4550
  • Fax: 772-398-4552
Mailing address:
  • Phone: 772-398-4550
  • Fax: 772-398-4552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP1627
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS22540
License Number StateFL

VIII. Authorized Official

Name: STUART S SHIPE
Title or Position: ACUPUNCTURE PHYSICIAN
Credential: D.O.M.
Phone: 772-398-4550