Provider Demographics
NPI:1831634740
Name:CULTURED BC CORP
Entity Type:Organization
Organization Name:CULTURED BC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAMILO
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-319-8597
Mailing Address - Street 1:1290 N RIDGE BLVD APT 922
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2896
Mailing Address - Country:US
Mailing Address - Phone:407-319-8597
Mailing Address - Fax:
Practice Address - Street 1:1290 N RIDGE BLVD APT 922
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2896
Practice Address - Country:US
Practice Address - Phone:407-319-8597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-31
Last Update Date:2016-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA67733225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty