=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598071532
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREASURE COAST INTEGRATIVE THERAPIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2010
-----------------------------------------------------
Last Update Date | 08/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1360 US HIGHWAY 1 SUITE 5
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-5703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-569-7770
-----------------------------------------------------
Fax | 772-569-7770
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1360 US HIGHWAY 1 SUITE 5
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-5703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-569-7770
-----------------------------------------------------
Fax | 772-569-7770
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PHILIP DYKE
-----------------------------------------------------
Credential | L.M.T.
-----------------------------------------------------
Telephone | 772-569-7770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | MA-20703
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------