Healthcare Provider Details

I. General information

NPI: 1326494006
Provider Name (Legal Business Name): PHOENIX RISES ACUPUNCTURE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 05/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 KENT RD SUITE 2A
ST AUGUSTINE FL
32086-6350
US

IV. Provider business mailing address

150 KENT RD SUITE 2A
ST AUGUSTINE FL
32086-6350
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP 3712
License Number StateFL

VIII. Authorized Official

Name: GORDANA SMITH
Title or Position: OWNER
Credential: LAC
Phone: 904-238-1000