MEDICARE: MS. JANICE L. VIDAL LMT

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	MA#43019	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA#43019	OTHER	FL	MASSAGE LICENSE
2	C2917	OTHER	FL	BCBS PROVIDER NUMBER

General Provider Information

NPI Number	:	1174681175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JANICE L. VIDAL LMT

Provider Business Mailing Address
First Line	:	897 N HOLLYWOOD CIR
Second Line	:
City	:	CRYSTAL RIVER
State	:	FL
Zip	:	34429-2644
Country	:	US
Telephone Number	:	352-795-3191
Fax Number	:	352-795-3191

Provider Business Practice Location Address
First Line	:	4027 N LECANTO HWY
Second Line	:
City	:	BEVERLY HILLS
State	:	FL
Zip	:	34465-3551
Country	:	US
Telephone Number	:	352-527-2515
Fax Number	:

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

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	07/08/2007

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