Healthcare Provider Details

I. General information

NPI: 1700316460
Provider Name (Legal Business Name): FRESH HEADS ORLANDO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 06/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2273 LEE RD STE 100
WINTER PARK FL
32789-7213
US

IV. Provider business mailing address

653 LAKE STONE CIR
PONTE VEDRA BEACH FL
32082-4342
US

V. Phone/Fax

Practice location:
  • Phone: 904-235-3157
  • Fax:
Mailing address:
  • Phone: 904-235-3157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name: MR. DWIGHT LEE OTTESEN
Title or Position: OWNER
Credential:
Phone: 904-686-4175