Provider Demographics
NPI:1437340585
Name:SANTA ROSA WELLNESS SPA, P.A.
Entity Type:Organization
Organization Name:SANTA ROSA WELLNESS SPA, P.A.
Other - Org Name:WEST FLORIDA BACK & NECK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERTHIAUME
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-654-6505
Mailing Address - Street 1:12671 US HIGHWAY 98 W
Mailing Address - Street 2:SUITE 211
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-8300
Mailing Address - Country:US
Mailing Address - Phone:850-654-6505
Mailing Address - Fax:850-654-6505
Practice Address - Street 1:12671 US HIGHWAY 98 W
Practice Address - Street 2:SUITE 211
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-8300
Practice Address - Country:US
Practice Address - Phone:850-654-6505
Practice Address - Fax:850-654-6505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 8469111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6025Medicare PIN