1679657373 NPI number — CHARLOTTE SLATTUM CLYNES LICENSED MASSAGE THE

Table of content: CHARLOTTE SLATTUM CLYNES LICENSED MASSAGE THE (NPI 1679657373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679657373 NPI number — CHARLOTTE SLATTUM CLYNES LICENSED MASSAGE THE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLYNES
Provider First Name:
CHARLOTTE
Provider Middle Name:
SLATTUM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICENSED MASSAGE THE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SLATTUM
Provider Other First Name:
CHARLOTTE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LICENSED MASSAGE THE
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679657373
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5350 SE RUNNING OAK CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34997
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-220-4115
Provider Business Mailing Address Fax Number:
772-220-4115

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1255 THELMA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34990
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-220-4115
Provider Business Practice Location Address Fax Number:
772-220-4115
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN3266662 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 225700000X , with the licence number: MA4695 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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