MEDICARE: WEST PALM MEDICAL SPA

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	261QP2000X	Physical Therapy Clinic/Center	MA70551	FL

General Provider Information

NPI Number	:	1821339953
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST PALM MEDICAL SPA

Provider Business Mailing Address
First Line	:	6383 10TH AVE N STE C
Second Line	:
City	:	GREENACRES
State	:	FL
Zip	:	33463
Country	:	US
Telephone Number	:	561-460-3058
Fax Number	:

Provider Business Practice Location Address
First Line	:	6383 10TH AVE N
Second Line	:	STE C
City	:	GREENACRES
State	:	FL
Zip	:	33463-1689
Country	:	US
Telephone Number	:	561-460-3058
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ALEXANDER JUSTO
Credential	:	MD
Telephone Number	:	561-460-3058

Provider Enumeration Date	:	03/14/2013
Last Update Date	:	03/14/2013

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