MEDICARE: MR. EDGAR HERNAN PERILLA 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	MA44539	FL

General Provider Information

NPI Number	:	1578877106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDGAR HERNAN PERILLA LMT

Provider Business Mailing Address
First Line	:	5160 SW 40TH AVE APT 5D
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33314-5751
Country	:	US
Telephone Number	:	954-303-1526
Fax Number	:

Provider Business Practice Location Address
First Line	:	5081 SHERIDAN ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-2831
Country	:	US
Telephone Number	:	954-966-1771
Fax Number	:

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

Provider Enumeration Date	:	08/06/2010
Last Update Date	:	08/06/2010

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