=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578965653
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY RESULTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2014
-----------------------------------------------------
Last Update Date | 12/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 475 NW PRIMA VISTA BLVD
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-8731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-800-3031
-----------------------------------------------------
Fax | 772-807-1409
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 475 NW PRIMA VISTA BLVD
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-8731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-800-3031
-----------------------------------------------------
Fax | 772-807-1409
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | DR. DANA D DAMERON
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 772-800-3037
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | OS11959
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------