Organization
FRESH HEADS LICE REMOVAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DWIGHT L OTTESEN (OWNER)
(904) 686-4175
Entity
Organization
Contact information
Practice address
13241 BARTRAM PARK BLVD UNIT 1801, JACKSONVILLE, FL 32258-5227
(904) 517-4087
Mailing address
653 LAKE STONE CIR, PONTE VEDRA BEACH, FL 32082-4342
(904) 235-3157
Taxonomy
Speciality
Code
Description
License number
State
247200000X
Other Technician
Primary
—
—
Other
Enumeration date
06/15/2017
Last updated
06/15/2017
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