MEDICARE: LILIANA 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	MA46089	FL

General Provider Information

NPI Number	:	1629407408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILIANA VIDAL LMT

Provider Business Mailing Address
First Line	:	2926 ROYAL PALM AVE
Second Line	:	APTO 1
City	:	MIAMI BEACH
State	:	FL
Zip	:	33140-4382
Country	:	US
Telephone Number	:	305-343-2646
Fax Number	:

Provider Business Practice Location Address
First Line	:	2926 ROYAL PALM AVE APT 1
Second Line	:	APTO 1
City	:	MIAMI BEACH
State	:	FL
Zip	:	33140-4342
Country	:	US
Telephone Number	:	305-343-2646
Fax Number	:

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

Provider Enumeration Date	:	11/02/2013
Last Update Date	:	11/02/2013

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