Provider Demographics
NPI:1699271700
Name:FLORIDA DANCER'S GALLERY
Entity type:Organization
Organization Name:FLORIDA DANCER'S GALLERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-882-8762
Mailing Address - Street 1:12323 SW 55TH ST STE 1010
Mailing Address - Street 2:
Mailing Address - City:COOPER CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33330-3312
Mailing Address - Country:US
Mailing Address - Phone:954-437-9910
Mailing Address - Fax:
Practice Address - Street 1:12323 SW 55TH ST STE 1010
Practice Address - Street 2:
Practice Address - City:COOPER CITY
Practice Address - State:FL
Practice Address - Zip Code:33330-3312
Practice Address - Country:US
Practice Address - Phone:954-437-9910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-05
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherEMPLOYEE IDENTIFICATION NUMBER