Provider Demographics
NPI:1881138279
Name:SPIRIT OF KEY WEST LLC
Entity type:Organization
Organization Name:SPIRIT OF KEY WEST LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HIMMELBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:678-765-8622
Mailing Address - Street 1:5629 HOLIDAY RD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-1519
Mailing Address - Country:US
Mailing Address - Phone:678-765-8622
Mailing Address - Fax:678-765-8621
Practice Address - Street 1:5629 HOLIDAY RD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-1519
Practice Address - Country:US
Practice Address - Phone:678-765-8622
Practice Address - Fax:678-765-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75152261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care