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General NPI Number Information
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NPI Number | 1669758710
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Entity Type | Organization
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Legal Business Name | FONG MENTAL & SPIRITUAL MASSAGE THERAPY, INC.
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Dates
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Enumeration Date | 11/02/2011
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Last Update Date | 11/04/2011
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Provider Practice Location Address
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Address Line | 4011 W FLAGLER ST SUITE 406
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City | CORAL GABLES
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State | FL
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Zip | 33134-1643
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Country | US
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Telephone | 786-294-0552
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Fax |
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Provider Business Mailing Address
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Address Line | 4011 W FLAGLER ST SUITE 406
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City | CORAL GABLES
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State | FL
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Zip | 33134-1643
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Country | US
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Telephone | 786-294-0552
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Fax |
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Authorized Official
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Title or Position | LICENSED MASSAGE THERAPIST
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Name | MR. FERNANDO LORENZO DOMINGUEZ
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Credential | MA 62152
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Telephone | 786-294-0552
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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 | 62152
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License Number State | FL
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