Provider Demographics
NPI:1871013649
Name:BODHI TRADITIONAL CHINESE MEDICINE INC
Entity Type:Organization
Organization Name:BODHI TRADITIONAL CHINESE MEDICINE INC
Other - Org Name:BODHI TCM
Other - Org Type:Other Name
Authorized Official - Title/Position:DR. OF CHINESE MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:IZQUIERDO
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, DOM
Authorized Official - Phone:321-312-0771
Mailing Address - Street 1:476 HIGHWAY A1A STE 2B
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-2331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:476 HIGHWAY A1A STE 8B
Practice Address - Street 2:
Practice Address - City:SATELLITE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-2331
Practice Address - Country:US
Practice Address - Phone:321-312-0771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3822171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1972031169OtherPERSONAL NPI