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General NPI Number Information
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NPI Number | 1104084300
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Entity Type | Individual
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Provider Name | LADON STACY LEWIS L.M.T.
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Gender | Male
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Dates
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Enumeration Date | 05/26/2008
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Last Update Date | 05/26/2008
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Provider Practice Location Address
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Address Line | 3650 NANTUCKET ISLAND DR APT. 101
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City | PORT ORANGE
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State | FL
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Zip | 32129-5336
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Country | US
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Telephone | 386-679-4996
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Fax | 386-322-3870
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Provider Business Mailing Address
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Address Line | PO BOX 422
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City | DAYTONA BEACH
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State | FL
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Zip | 32115-0422
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Country | US
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Telephone | 386-679-4996
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Fax | 386-322-3870
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA52351
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License Number State | FL
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