Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA 59142 | FL |
NPI | 1003180951 |
---|---|
Provider Name | Alfonso Macedonio |
First Address | Ruskin, FL 33570-5535 |
Second Address | Pinellas Park, FL 33781-3540 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2012 |
Last Update Date | 23/02/2012 |