MEDICARE: GO SPA WELLNESS

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	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1497440846
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GO SPA WELLNESS

Provider Business Mailing Address
First Line	:	341 JAMES CIR
Second Line	:
City	:	LAKE ALFRED
State	:	FL
Zip	:	33850-2753
Country	:	US
Telephone Number	:	863-449-0929
Fax Number	:

Provider Business Practice Location Address
First Line	:	341 JAMES CIR
Second Line	:
City	:	LAKE ALFRED
State	:	FL
Zip	:	33850-2753
Country	:	US
Telephone Number	:	863-449-0929
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MASSAGE THERAPIST
Name	:	LORAINE GORDON
Credential	:
Telephone Number	:	863-449-0929

Provider Enumeration Date	:	04/10/2023
Last Update Date	:	04/10/2023

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Directions to “GO SPA WELLNESS ” Practice Location

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