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General NPI Number Information
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NPI Number | 1063656791
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Entity Type | Organization
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Legal Business Name | SPA BLU
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Dates
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Enumeration Date | 04/24/2009
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Last Update Date | 04/24/2009
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Provider Practice Location Address
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Address Line | 57 UPTOWN GRAYTON CIR STE A
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City | SANTA ROSA BEACH
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State | FL
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Zip | 32459-8814
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Country | US
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Telephone | 850-231-5784
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Fax | 850-231-4718
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Provider Business Mailing Address
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Address Line | 57 A UPTOWN GRAYTON CIRCLE
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City | GRAYTON BEACH
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State | FL
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Zip | 32459
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Country | US
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Telephone | 850-231-5784
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Fax | 850-231-4718
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Authorized Official
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Title or Position | OWNER/LMT
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Name | KRISTA DUMBLETON
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Credential | LMT
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Telephone | 850-231-5784
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | MM16325
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License Number State | FL
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