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General NPI Number Information
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NPI Number | 1912302787
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Entity Type | Organization
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Legal Business Name | MIND, BODY & MODERN MEDICINE, LLC
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Dates
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Enumeration Date | 10/23/2014
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Last Update Date | 10/23/2014
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Provider Practice Location Address
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Address Line | 19401 SHUMARD OAK DR CLARITY MEDSPA
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City | LAND O'LAKES
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State | FL
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Zip | 34638
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Country | US
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Telephone | 727-264-1364
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Fax |
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Provider Business Mailing Address
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Address Line | 8341 CAROLYN DR
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City | PORT RICHEY
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State | FL
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Zip | 34668-6210
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Country | US
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Telephone | 727-264-1364
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MS. FAITH I BEVAN
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Credential | PA-C
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Telephone | 727-992-3440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 9101970
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License Number State | FL
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