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General NPI Number Information
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NPI Number | 1639238777
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Entity Type | Individual
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Provider Name | RANDOLPH STEVEN DECOS LMT
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Gender | Male
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 12/08/2011
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Provider Practice Location Address
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Address Line | 2106 BISPHAM ROAD SUITE A
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City | SARASOTA
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State | FL
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Zip | 34231
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Country | US
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Telephone | 941-925-3557
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Fax | 941-925-3557
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Provider Business Mailing Address
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Address Line | 4084 LINWOOD ST
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City | SARASOTA
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State | FL
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Zip | 34232-3806
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Country | US
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Telephone | 941-378-9072
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Fax |
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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 | MA0019618
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License Number State | FL
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