Healthcare Provider Details

I. General information

NPI: 1548477441
Provider Name (Legal Business Name): TYRONE FLETCHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9469 SHERIDAN ST.
COOPER F FL
33024
US

IV. Provider business mailing address

7580 ATLANTA ST.
HOLLYWOOD FL
33024
US

V. Phone/Fax

Practice location:
  • Phone: 954-432-5775
  • Fax:
Mailing address:
  • Phone: 954-394-2393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA46116
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: