Healthcare Provider Details

I. General information

NPI: 1790808566
Provider Name (Legal Business Name): RAYFORD BEAUFORD ALLEN III LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19007 NORTH DALE MABRY HWY
LUTZ FL
33548
US

IV. Provider business mailing address

14907 GREELEY DR
TAMPA FL
33625-1963
US

V. Phone/Fax

Practice location:
  • Phone: 813-298-7684
  • Fax: 813-968-7667
Mailing address:
  • Phone: 813-298-7684
  • Fax: 813-968-7667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA-28726
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: