Provider Demographics
NPI:1164130613
Name:SUN MIRACLE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:SUN MIRACLE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANTA
Authorized Official - Middle Name:K
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:AGNP-C
Authorized Official - Phone:727-741-8475
Mailing Address - Street 1:6740 CROSSWINDS DR N STE C
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5472
Mailing Address - Country:US
Mailing Address - Phone:727-954-0010
Mailing Address - Fax:
Practice Address - Street 1:13575 58TH ST N STE 200
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33760-3739
Practice Address - Country:US
Practice Address - Phone:727-741-8475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty