Healthcare Provider Details

I. General information

NPI: 1396288635
Provider Name (Legal Business Name): THRIVE SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2166 WILTON DR
WILTON MANORS FL
33305-2107
US

IV. Provider business mailing address

2166 WILTON DR
WILTON MANORS FL
33305-2107
US

V. Phone/Fax

Practice location:
  • Phone: 954-441-4244
  • Fax:
Mailing address:
  • Phone: 954-441-4244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberPS35134
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME83875
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9104055
License Number StateFL

VIII. Authorized Official

Name: DR. MARY VAN
Title or Position: DIRECTOR OF OPERATIONS
Credential: PHARM D, DACBN
Phone: 954-557-7401