=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295702959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROGER LEE ALDERMAN JR. LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4245 TANGELO AVE
-----------------------------------------------------
City | TITUSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32780-6574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-271-8558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4245 TANGELO AVE
-----------------------------------------------------
City | TITUSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32780-6574
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-271-8558
-----------------------------------------------------
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 | MA 44245
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA44245
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------