Healthcare Provider Details

I. General information

NPI: 1992171037
Provider Name (Legal Business Name): RADIANCE HEALTH AND BEAUTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 W FAIRBANKS AVE
WINTER PARK FL
32789-4559
US

IV. Provider business mailing address

936 S LAKE STERLING CT
CASSELBERRY FL
32707-5400
US

V. Phone/Fax

Practice location:
  • Phone: 407-758-7874
  • Fax:
Mailing address:
  • Phone: 407-758-7874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberFS878771
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60398
License Number StateFL

VIII. Authorized Official

Name: ROCIO I LORA
Title or Position: FULL SPECIALIST/LMT
Credential: FS/LMT
Phone: 407-758-7874