Provider Demographics
NPI:1467863050
Name:SHANTI OM SPA
Entity Type:Organization
Organization Name:SHANTI OM SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:GEGUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-243-3779
Mailing Address - Street 1:321 NE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33444-3801
Mailing Address - Country:US
Mailing Address - Phone:561-243-3779
Mailing Address - Fax:
Practice Address - Street 1:321 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33444-3801
Practice Address - Country:US
Practice Address - Phone:561-243-3779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3327171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty