=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790572220
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIGUEL LEIVA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2025
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 SQUIRE DR
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32607-5709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-641-4899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 SQUIRE DR
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32607-5709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-641-4899
-----------------------------------------------------
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 | MA100446
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------