=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922255660
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES RUFUS COULLIETTE JR. LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2008
-----------------------------------------------------
Last Update Date | 08/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33306 PORTAL DR
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34788-3171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-253-2353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 895321
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34789-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-455-7828
-----------------------------------------------------
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 | MA-45688
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------