Healthcare Provider Details

I. General information

NPI: 1114154176
Provider Name (Legal Business Name): LIUVAN CORRALES LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 N HIMES AVE
TAMPA FL
33607-4219
US

IV. Provider business mailing address

1914 N HIMES AVE
TAMPA FL
33607-4219
US

V. Phone/Fax

Practice location:
  • Phone: 813-374-9142
  • Fax: 813-374-9144
Mailing address:
  • Phone: 813-374-9142
  • Fax: 813-374-9144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number56369
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: