MEDICARE: JERALDINE VEGA MM

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	:	1205124963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERALDINE VEGA MM

Provider Business Mailing Address
First Line	:	9601 FONTAINEBLEAU BLVD
Second Line	:	# 516
City	:	MIAMI
State	:	FL
Zip	:	33172-6812
Country	:	US
Telephone Number	:	786-308-5672
Fax Number	:

Provider Business Practice Location Address
First Line	:	9601 FONTAINEBLEAU BLVD
Second Line	:	# 516
City	:	MIAMI
State	:	FL
Zip	:	33172-6812
Country	:	US
Telephone Number	:	786-308-5672
Fax Number	:

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

Provider Enumeration Date	:	07/15/2011
Last Update Date	:	07/15/2011

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