Healthcare Provider Details

I. General information

NPI: 1699898098
Provider Name (Legal Business Name): KEVIN MICHAEL DONOVAN L.M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

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

12115 PANAMA CITY BEACH PKWY
PANAMA CITY BEACH FL
32407-2609
US

IV. Provider business mailing address

4932 BEACH DR
PANAMA CITY BEACH FL
32408-6801
US

V. Phone/Fax

Practice location:
  • Phone: 850-236-5664
  • Fax:
Mailing address:
  • Phone: 850-596-5621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 44336
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: