Healthcare Provider Details

I. General information

NPI: 1477959856
Provider Name (Legal Business Name): SPACE COAST LYMPHEDEMA CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 SPYGLASS CT. SUITE 120
VIERA FL
32940
US

IV. Provider business mailing address

7000 SPYGLASS CT. SUITE 120
VIERA FL
32940
US

V. Phone/Fax

Practice location:
  • Phone: 321-241-6543
  • Fax: 321-241-6513
Mailing address:
  • Phone: 321-241-6543
  • Fax: 321-241-6513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT14733
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT12356
License Number StateFL

VIII. Authorized Official

Name: MRS. ROSANNE BESSENAIRE
Title or Position: CEO
Credential: PT
Phone: 321-241-6543