Provider Demographics
NPI:1255738019
Name:CLEARWATER BEACH SPA, INC.
Entity type:Organization
Organization Name:CLEARWATER BEACH SPA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAUDE
Authorized Official - Middle Name:GIBSON
Authorized Official - Last Name:HOOTEN
Authorized Official - Suffix:III
Authorized Official - Credentials:LMT
Authorized Official - Phone:727-460-4789
Mailing Address - Street 1:1154 GRANADA ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-1036
Mailing Address - Country:US
Mailing Address - Phone:727-461-7041
Mailing Address - Fax:
Practice Address - Street 1:641 1/2 MANDALAY AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33767-1523
Practice Address - Country:US
Practice Address - Phone:727-461-7041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16689225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty