Healthcare Provider Details

I. General information

NPI: 1013187574
Provider Name (Legal Business Name): DEBBIE'S DAY SPA & SALON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 ANASTASIA BLVD
ST AUGUSTINE FL
32080-4508
US

IV. Provider business mailing address

403 ANASTASIA BLVD
ST AUGUSTINE FL
32080-4508
US

V. Phone/Fax

Practice location:
  • Phone: 904-825-0569
  • Fax:
Mailing address:
  • Phone: 904-825-0569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMM9360
License Number StateFL

VIII. Authorized Official

Name: MR. SHANNON THEED
Title or Position: CHIEF OPERATIONAL OFFICER
Credential:
Phone: 904-825-0569