MEDICARE: USVI MEDICAL DAY SPA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1063787844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	USVI MEDICAL DAY SPA, LLC

Provider Business Mailing Address
First Line	:	4001 RAPHUNE HILL RD
Second Line	:	SUITE 108
City	:	ST THOMAS
State	:	VI
Zip	:	00802-2905
Country	:	US
Telephone Number	:	340-774-2331
Fax Number	:	340-774-2353

Provider Business Practice Location Address
First Line	:	4001 RAPHUNE HILL RD
Second Line	:	SUITE 108
City	:	ST THOMAS
State	:	VI
Zip	:	00802-2905
Country	:	US
Telephone Number	:	340-774-2331
Fax Number	:	340-774-2353

Authorized Official
Title or Position	:	MEMBER
Name	:	RYAN D WALLACE
Credential	:
Telephone Number	:	316-258-3817

Provider Enumeration Date	:	03/13/2012
Last Update Date	:	03/13/2012

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