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General NPI Number Information
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NPI Number | 1164130613
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Entity Type | Organization
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Legal Business Name | SUN MIRACLE WELLNESS CENTER LLC
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Dates
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Enumeration Date | 11/14/2022
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Last Update Date | 09/25/2023
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Provider Practice Location Address
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Address Line | 13575 58TH ST N STE 200
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City | CLEARWATER
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State | FL
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Zip | 33760-3739
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Country | US
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Telephone | 727-741-8475
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Fax |
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Provider Business Mailing Address
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Address Line | 6740 CROSSWINDS DR N STE C
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City | ST PETERSBURG
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State | FL
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Zip | 33710-5472
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Country | US
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Telephone | 727-954-0010
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHANTA K DAVIS
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Credential | AGNP-C
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Telephone | 727-741-8475
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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