MEDICARE: TINA DESTRO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1104234673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA DESTRO

Provider Business Mailing Address
First Line	:	135 THORNDALE AVE
Second Line	:
City	:	WEST SENECA
State	:	NY
Zip	:	14224-1877
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	135 THORNDALE AVE
Second Line	:
City	:	WEST SENECA
State	:	NY
Zip	:	14224-1877
Country	:	US
Telephone Number	:	716-480-0242
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2014
Last Update Date	:	07/29/2014

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Directions to “ TINA DESTRO ” Practice Location

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