=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598047698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED HEALTHCARE CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2011
-----------------------------------------------------
Last Update Date | 05/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9114 TOWN CENTER PKWY STE 101
-----------------------------------------------------
City | LAKEWOOD RANCH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34202-5053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-351-4949
-----------------------------------------------------
Fax | 941-351-3033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9114 TOWN CENTER PKWY STE 101
-----------------------------------------------------
City | LAKEWOOD RANCH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34202-5054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-351-4949
-----------------------------------------------------
Fax | 941-351-3033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MR. MARIO DUBE
-----------------------------------------------------
Credential | D.O.M.
-----------------------------------------------------
Telephone | 941-351-4949
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | AP2931
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP2931
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------