Healthcare Provider Details

I. General information

NPI: 1457713976
Provider Name (Legal Business Name): BLOOMINGDALE ACUPUNCTURE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10015 PARK PLACE AVE
RIVERVIEW FL
33578-5303
US

IV. Provider business mailing address

10419 KANKAKEE LN
RIVERVIEW FL
33578-8302
US

V. Phone/Fax

Practice location:
  • Phone: 813-341-2200
  • Fax: 801-469-0016
Mailing address:
  • Phone: 813-341-2200
  • Fax: 801-469-0016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP1469
License Number StateFL

VIII. Authorized Official

Name: DR. GUILLERMO CACERES
Title or Position: OWNER
Credential: LAC, AP
Phone: 813-341-2200