=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427366624
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT C WEDDEL LMT MA60333
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2010
-----------------------------------------------------
Last Update Date | 09/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 ALABAMA RD N STE 1
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33936-6829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-369-9986
-----------------------------------------------------
Fax | 239-674-7645
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 ALABAMA RD N STE 1
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33936-6829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-369-9986
-----------------------------------------------------
Fax | 239-674-7645
-----------------------------------------------------
=====================================================
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 | MA60333
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------