Provider Demographics
NPI:1912332925
Name:THE SPA AT ST LUCIE WEST
Entity Type:Organization
Organization Name:THE SPA AT ST LUCIE WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:LE PERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-343-8772
Mailing Address - Street 1:312 NW BETHANY DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-3578
Mailing Address - Country:US
Mailing Address - Phone:772-343-8772
Mailing Address - Fax:
Practice Address - Street 1:312 NW BETHANY DR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-3578
Practice Address - Country:US
Practice Address - Phone:772-343-8772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty