=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669807293
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RITA ELLEN VIDUR LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2013
-----------------------------------------------------
Last Update Date | 09/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2883 S UNIVERSITY DR
-----------------------------------------------------
City | DAVIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-424-0055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 436 TAMARIND DR
-----------------------------------------------------
City | HALLANDALE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33009-6542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-629-9479
-----------------------------------------------------
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 | MA73051
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------