=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598199135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D'VINE MEDICAL SPA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2013
-----------------------------------------------------
Last Update Date | 10/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 590 MIDDLEBURY RD SUITE 1
-----------------------------------------------------
City | MIDDLEBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06762-2562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-232-0208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 851 SUITE 1
-----------------------------------------------------
City | MIDDLEBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06762-0851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-232-0208
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MRS. NADINE MACARON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-232-0208
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------