=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144698713
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPA LONGEVITA ACUPUNCTURE & HERBAL MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2015
-----------------------------------------------------
Last Update Date | 09/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3730 AVALON PARK BLVD E # 8
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32828-4805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-440-3990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3730 AVALON PARK BLVD E # 8
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32828-4805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-440-3990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. BROOKE E HIGGINIS
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 440-440-3990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP2936
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------