Healthcare Provider Details

I. General information

NPI: 1396210860
Provider Name (Legal Business Name): CHISIE GUMOBAO KLINGLESMITH AP, DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 INDIAN RIVER BLVD STE C130
VERO BEACH FL
32960-7134
US

IV. Provider business mailing address

404 RED SAIL WAY
SATELLITE BEACH FL
32937-3720
US

V. Phone/Fax

Practice location:
  • Phone: 772-770-6184
  • Fax: 772-770-6310
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP3986
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: