Healthcare Provider Details

I. General information

NPI: 1013422484
Provider Name (Legal Business Name): EVERILDO VIGISTAIN-RUIZ MASSAGE THERAPIST MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 12/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 E 9TH ST
HIALEAH FL
33010-4553
US

IV. Provider business mailing address

755 E 9TH ST
HIALEAH FL
33010-4553
US

V. Phone/Fax

Practice location:
  • Phone: 305-805-2550
  • Fax:
Mailing address:
  • Phone: 305-805-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA50948
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: