Healthcare Provider Details

I. General information

NPI: 1932745346
Provider Name (Legal Business Name): ALPHA WAVE HEALTH CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E TOWN PL STE 100
ST AUGUSTINE FL
32092-2726
US

IV. Provider business mailing address

101 E TOWN PL STE 100
ST AUGUSTINE FL
32092-2726
US

V. Phone/Fax

Practice location:
  • Phone: 386-763-1400
  • Fax:
Mailing address:
  • Phone: 386-763-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GORAN MLADEN
Title or Position: OWNER
Credential:
Phone: 386-871-1975