Provider Demographics
NPI:1265676902
Name:SPA SARASOTA, LLC
Entity Type:Organization
Organization Name:SPA SARASOTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN-PAUL
Authorized Official - Middle Name:H
Authorized Official - Last Name:D'ANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:904-738-0369
Mailing Address - Street 1:1147 EDGEWOOD AVE S
Mailing Address - Street 2:SUITE 5
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-0810
Mailing Address - Country:US
Mailing Address - Phone:904-738-0369
Mailing Address - Fax:
Practice Address - Street 1:1147 EDGEWOOD AVE S
Practice Address - Street 2:SUITE 5
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-0810
Practice Address - Country:US
Practice Address - Phone:904-738-0369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZMM21136261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service