Provider Demographics
NPI:1306394168
Name:THE 5 ELEMENTS SPA & LONGEVITY CENTER
Entity Type:Organization
Organization Name:THE 5 ELEMENTS SPA & LONGEVITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATALINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RESTREPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-607-2335
Mailing Address - Street 1:2288 WILTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305
Mailing Address - Country:US
Mailing Address - Phone:954-533-2604
Mailing Address - Fax:
Practice Address - Street 1:2288 WILTON DRIVE
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305
Practice Address - Country:US
Practice Address - Phone:954-533-2604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM35287302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization