Provider Demographics
NPI:1396288635
Name:THRIVE SPA
Entity type:Organization
Organization Name:THRIVE SPA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D, DACBN
Authorized Official - Phone:954-557-7401
Mailing Address - Street 1:2166 WILTON DR
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-2107
Mailing Address - Country:US
Mailing Address - Phone:954-441-4244
Mailing Address - Fax:
Practice Address - Street 1:2166 WILTON DR
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-2107
Practice Address - Country:US
Practice Address - Phone:954-441-4244
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83875208100000X
FLPA9104055363A00000X
FLPS35134133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty