Healthcare Provider Details

I. General information

NPI: 1083628747
Provider Name (Legal Business Name): RICKY KRIESBERG LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8862 NW 29TH PL
CORAL SPRINGS FL
33065-5365
US

IV. Provider business mailing address

8862 NW 29TH PL
CORAL SPRINGS FL
33065-5365
US

V. Phone/Fax

Practice location:
  • Phone: 954-341-7880
  • Fax: 954-575-0292
Mailing address:
  • Phone: 954-341-7880
  • Fax: 954-575-0292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA35513
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: