MEDICARE: MR. DESMOND DEPASS L.M.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA78630	FL
2	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1104209410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DESMOND DEPASS L.M.T.

Provider Business Mailing Address
First Line	:	16951 SW 63RD MNR
Second Line	:
City	:	SOUTHWEST RANCHES
State	:	FL
Zip	:	33331
Country	:	US
Telephone Number	:	954-471-7950
Fax Number	:

Provider Business Practice Location Address
First Line	:	4621 N UNIVERSITY DR.
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067
Country	:	US
Telephone Number	:	954-471-7950
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2015
Last Update Date	:	07/22/2015

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