Basic Information
| Provider Information | |||||||||
| NPI: | 1043654262 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY TREE ACUPUNCTURE PL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1334 FLORENCE CT | ||||||||
| Address2: | |||||||||
| City: | HOLLY HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321172310 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 112 ORANGE AVE | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321144338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3869445855 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2013 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | MEJIA | ||||||||
| AuthorizedOfficialFirstName: | JORGE | ||||||||
| AuthorizedOfficialMiddleName: | ENRIQUE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3869445855 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | AP, DOM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | AP3134 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Acupuncturist |
No ID Information.