=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861232423
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHINE AYG LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2024
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 N FEDERAL HWY
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33432-2737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-409-4854
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 N FEDERAL HWY
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33432-2737
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-409-4854
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. ANDREA BEATRIZ PENA CASTILLO SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-660-3711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------