Healthcare Provider Details

I. General information

NPI: 1992134159
Provider Name (Legal Business Name): FALYYN LODERBAUER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3558 E DELIGHT ST
HERNANDO FL
34442-2510
US

IV. Provider business mailing address

3558 E DELIGHT ST
HERNANDO FL
34442-2510
US

V. Phone/Fax

Practice location:
  • Phone: 352-422-7921
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA35054
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: