Healthcare Provider Details

I. General information

NPI: 1518263755
Provider Name (Legal Business Name): MR. VINCENT CHARLES CICCHETTI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2011
Last Update Date: 02/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10401 US HIGHWAY 441 STE 326
LEESBURG FL
34788-7250
US

IV. Provider business mailing address

10401 US HIGHWAY 441 STE 326
LEESBURG FL
34788-7250
US

V. Phone/Fax

Practice location:
  • Phone: 135-261-7521
  • Fax:
Mailing address:
  • Phone: 135-261-7521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA52943
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: