Healthcare Provider Details

I. General information

NPI: 1902316201
Provider Name (Legal Business Name): KESARA MAI NGAM LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 WEST OAK DRIVE
LAKELAND FL
33803
US

IV. Provider business mailing address

117 W OAK DR
LAKELAND FL
33803-3808
US

V. Phone/Fax

Practice location:
  • Phone: 863-812-9388
  • Fax:
Mailing address:
  • Phone: 863-812-9388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA78493
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: