Provider Demographics
NPI:1376024851
Name:BEAUTY AND WELLNESS MED SPA
Entity Type:Organization
Organization Name:BEAUTY AND WELLNESS MED SPA
Other - Org Name:FD INTEGRATIVE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:FREDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUQUE
Authorized Official - Suffix:
Authorized Official - Credentials:ACUPUNCTURE PHYSICIA
Authorized Official - Phone:786-547-2091
Mailing Address - Street 1:7044 NW 113TH PL
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-4542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1470 NW 107TH AVE STE A
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:FL
Practice Address - Zip Code:33172-2734
Practice Address - Country:US
Practice Address - Phone:786-547-2091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FD INTEGRATIVE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP-3765171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty