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General NPI Number Information
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NPI Number | 1265676902
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Entity Type | Organization
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Legal Business Name | SPA SARASOTA, LLC
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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 | 1147 EDGEWOOD AVE S SUITE 5
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City | JACKSONVILLE
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State | FL
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Zip | 32205-0810
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Country | US
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Telephone | 904-738-0369
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Fax |
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Provider Business Mailing Address
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Address Line | 1147 EDGEWOOD AVE S SUITE 5
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City | JACKSONVILLE
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State | FL
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Zip | 32205-0810
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Country | US
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Telephone | 904-738-0369
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JEAN-PAUL H. D'ANGELO
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Credential | L.M.T.
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Telephone | 904-738-0369
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | MM21136
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License Number State | ZZ
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