=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508553157
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAGE MIKAYLA MAIOLO DC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2023
-----------------------------------------------------
Last Update Date | 04/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 S CHARLES RICHARD BEALL BLVD STE 111A
-----------------------------------------------------
City | DEBARY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32713-3740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-243-0224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3330 WILLOW OAK DR
-----------------------------------------------------
City | EDGEWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32141-6503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-333-7378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 14509
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------