Provider Demographics
NPI:1083805188
Name:A HEALTHY PLACE PA
Entity Type:Organization
Organization Name:A HEALTHY PLACE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEZI
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-677-4180
Mailing Address - Street 1:55 N OLD KINGS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9506
Mailing Address - Country:US
Mailing Address - Phone:386-677-4180
Mailing Address - Fax:386-677-4430
Practice Address - Street 1:55 N OLD KINGS RD
Practice Address - Street 2:SUITE A
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9506
Practice Address - Country:US
Practice Address - Phone:386-677-4180
Practice Address - Fax:386-677-4430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2943Medicare PIN
FLH46382Medicare UPIN