Healthcare Provider Details

I. General information

NPI: 1992937726
Provider Name (Legal Business Name): KEVIN M. WADE LMT, CINT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13830 58TH ST N STE. 404
CLEARWATER FL
33760-3720
US

IV. Provider business mailing address

13830 58TH ST N STE. 404
CLEARWATER FL
33760-3720
US

V. Phone/Fax

Practice location:
  • Phone: 727-347-4325
  • Fax: 727-538-5787
Mailing address:
  • Phone: 727-347-4325
  • Fax: 727-538-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA54985
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: