Healthcare Provider Details

I. General information

NPI: 1801237722
Provider Name (Legal Business Name): EILEEN LASSITER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51C CORDOVA ST
ST AUGUSTINE FL
32084-3628
US

IV. Provider business mailing address

6831 SANDALWOOD LN
NAPLES FL
34109-0511
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-0590
  • Fax:
Mailing address:
  • Phone: 904-910-8811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA62944
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: