Healthcare Provider Details

I. General information

NPI: 1932004199
Provider Name (Legal Business Name): TRISTAN LUKE DANCER LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 SHASTA CT
JACKSONVILLE FL
32207-5724
US

IV. Provider business mailing address

4004 SHASTA CT
JACKSONVILLE FL
32207-5724
US

V. Phone/Fax

Practice location:
  • Phone: 904-874-5369
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA109953
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: