Healthcare Provider Details

I. General information

NPI: 1699046417
Provider Name (Legal Business Name): BLASA A MOYA MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 SW 138TH CT APT 606
MIAMI FL
33183-2266
US

IV. Provider business mailing address

6520 SW 138TH CT APT 606
MIAMI FL
33183-2266
US

V. Phone/Fax

Practice location:
  • Phone: 786-413-5861
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 63406
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: