Healthcare Provider Details

I. General information

NPI: 1750627600
Provider Name (Legal Business Name): ITZIA MARIA HURTADO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3041 FAIRWAY DR
FORT PIERCE FL
34982-4319
US

IV. Provider business mailing address

3041 FAIRWAY DR
FORT PIERCE FL
34982-4319
US

V. Phone/Fax

Practice location:
  • Phone: 772-528-5873
  • Fax:
Mailing address:
  • Phone: 772-528-5873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA63593
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: