MEDICARE: AUGUSTO MIKHAIL PERNIA L.M.T

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	A55666	FL

General Provider Information

NPI Number	:	1790016889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUGUSTO MIKHAIL PERNIA L.M.T

Provider Business Mailing Address
First Line	:	3434 W COLUMBUS DR
Second Line	:	SUITE 204
City	:	TAMPA
State	:	FL
Zip	:	33607-1860
Country	:	US
Telephone Number	:	813-872-7120
Fax Number	:	813-872-7143

Provider Business Practice Location Address
First Line	:	3434 W COLUMBUS DR
Second Line	:	SUITE 204
City	:	TAMPA
State	:	FL
Zip	:	33607-1860
Country	:	US
Telephone Number	:	813-872-7120
Fax Number	:	813-872-7143

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

Provider Enumeration Date	:	01/29/2010
Last Update Date	:	01/29/2010

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