=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912158973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWEETWATER AESTHETIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2008
-----------------------------------------------------
Last Update Date | 10/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7389 DAVIE ROAD EXT
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-443-6681
-----------------------------------------------------
Fax | 954-443-6683
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7389 DAVIE ROAD EXT
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-443-6681
-----------------------------------------------------
Fax | 954-443-6683
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MARTHA C FONSECA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-213-7865
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 225700000X
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------