=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871013649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODHI TRADITIONAL CHINESE MEDICINE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2017
-----------------------------------------------------
Last Update Date | 01/13/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 S HARBOR CITY BLVD STE 101
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901-1382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-312-0771
-----------------------------------------------------
Fax | 352-204-8490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 304 S HARBOR CITY BLVD STE 101
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901-1382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-312-0771
-----------------------------------------------------
Fax | 352-204-8490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR. OF CHINESE MEDICINE
-----------------------------------------------------
Name | DR. ANDREA IZQUIERDO
-----------------------------------------------------
Credential | LAC, DOM
-----------------------------------------------------
Telephone | 321-312-0771
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AP3822
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------