Healthcare Provider Details

I. General information

NPI: 1770966731
Provider Name (Legal Business Name): JESSE RONALD SALMON LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 LOOKOUT PL
MAITLAND FL
32751-8433
US

IV. Provider business mailing address

595 W CHURCH ST APT. 732
ORLANDO FL
32805-2285
US

V. Phone/Fax

Practice location:
  • Phone: 407-620-8764
  • Fax:
Mailing address:
  • Phone: 407-620-8764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA46094
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA46094
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: