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General NPI Number Information
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NPI Number | 1033642913
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Entity Type | Organization
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Legal Business Name | VIVID RECOVERY LLC
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Dates
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Enumeration Date | 04/06/2017
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Last Update Date | 04/06/2017
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Provider Practice Location Address
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Address Line | 3101 MAGUIRE BLVD
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City | ORLANDO
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State | FL
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Zip | 32803-3763
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Country | US
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Telephone | 727-776-9949
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Fax |
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Provider Business Mailing Address
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Address Line | 5005 GARDENS DR
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City | ORLANDO
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State | FL
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Zip | 32812-8782
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Country | US
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Telephone | 727-776-9949
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Fax |
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Authorized Official
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Title or Position | ACUPUNCTURE PHYSICIAN
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Name | DR. VERONIKA TYNES
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Credential | DIPL OM, LAC
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Telephone | 727-776-9949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AP03778
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License Number State | FL
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