Healthcare Provider Details

I. General information

NPI: 1215296090
Provider Name (Legal Business Name): AJAYI MILLER L.M.T
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 W BUSCH BLVD STE 201 A
TAMPA FL
33612-7621
US

IV. Provider business mailing address

1435 W BUSCH BLVD STE 201 A
TAMPA FL
33612-7621
US

V. Phone/Fax

Practice location:
  • Phone: 813-473-2744
  • Fax: 813-434-1624
Mailing address:
  • Phone: 813-473-2744
  • Fax: 813-434-1624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number15904
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number15904
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 68053
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: