MEDICARE: LICE AWAY TODAY LLC

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	242T00000X	Perfusionist

General Provider Information

NPI Number	:	1205376415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LICE AWAY TODAY LLC

Provider Business Mailing Address
First Line	:	4308 W EL PRADO BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-8405
Country	:	US
Telephone Number	:	813-410-4860
Fax Number	:

Provider Business Practice Location Address
First Line	:	4308 W EL PRADO BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-8405
Country	:	US
Telephone Number	:	813-410-4860
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MICHELLE CHERRY
Credential	:
Telephone Number	:	813-410-4860

Provider Enumeration Date	:	03/07/2017
Last Update Date	:	03/07/2017

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