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General NPI Number Information
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NPI Number | 1376900019
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Entity Type | Organization
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Legal Business Name | AMETHYST WELLNESS LLC
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Dates
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Enumeration Date | 01/26/2016
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Last Update Date | 02/08/2016
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Provider Practice Location Address
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Address Line | 145 CYPRESS POINT PKWY SUITE 208B
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City | PALM COAST
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State | FL
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Zip | 32164-8426
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Country | US
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Telephone | 386-503-7950
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Fax |
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Provider Business Mailing Address
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Address Line | 51 RENWORTH LN
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City | PALM COAST
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State | FL
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Zip | 32164-6627
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Country | US
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Telephone | 386-503-7950
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AMY COOPERSMITH
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Credential | DNP/ARNP
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Telephone | 386-503-7950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 9242220
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License Number State | FL
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