Healthcare Provider Details

I. General information

NPI: 1700355732
Provider Name (Legal Business Name): MIMI CAROLINE VREELAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2018
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 A1A S STE B2
SAINT AUGUSTINE FL
32080-2919
US

IV. Provider business mailing address

13 EUGENE PL
SAINT AUGUSTINE FL
32080-5338
US

V. Phone/Fax

Practice location:
  • Phone: 904-814-4323
  • Fax:
Mailing address:
  • Phone: 904-814-4323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP2950
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: