Healthcare Provider Details

I. General information

NPI: 1649853409
Provider Name (Legal Business Name): MICHAEL DZIEKIEWICZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3204 MONTAGUE AVE
SPRING HILL FL
34608-4155
US

IV. Provider business mailing address

3204 MONTAGUE AVE
SPRING HILL FL
34608-4155
US

V. Phone/Fax

Practice location:
  • Phone: 727-741-4673
  • Fax:
Mailing address:
  • Phone: 727-741-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA95538
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: