Healthcare Provider Details

I. General information

NPI: 1184088510
Provider Name (Legal Business Name): GORDANA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 KENT RD STE 2A
ST AUGUSTINE FL
32086-6485
US

IV. Provider business mailing address

5287 CYPRESS LINKS BLVD
ELKTON FL
32033-4044
US

V. Phone/Fax

Practice location:
  • Phone: 904-238-1000
  • Fax:
Mailing address:
  • Phone: 904-238-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number3712
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number53210
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: