Provider Demographics
NPI:1972156289
Name:BON SALUT ORGANIC MED SPA
Entity Type:Organization
Organization Name:BON SALUT ORGANIC MED SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FARAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-692-9465
Mailing Address - Street 1:14846 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-2701
Mailing Address - Country:US
Mailing Address - Phone:941-876-3577
Mailing Address - Fax:
Practice Address - Street 1:14846 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-2701
Practice Address - Country:US
Practice Address - Phone:941-876-3577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-17
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1003885815Medicaid