Healthcare Provider Details

I. General information

NPI: 1376701086
Provider Name (Legal Business Name): ROBERTA ANNE HOAG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 BRITTANY AVE
PORT ORANGE FL
32127-5914
US

IV. Provider business mailing address

207 BRITTANY AVE
PORT ORANGE FL
32127-5914
US

V. Phone/Fax

Practice location:
  • Phone: 386-761-1642
  • Fax:
Mailing address:
  • Phone: 386-761-1642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA34432
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: