=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245010180
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GENEVA MANILOVA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2023
-----------------------------------------------------
Last Update Date | 08/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 SE 6TH ST STE 1723
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-417-5540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7901 4TH ST N STE 300
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33702-4399
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-575-1161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 102436
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------