MEDICARE: EVELYN RUSSO 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	MA40587	FL

General Provider Information

NPI Number	:	1114099108
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVELYN RUSSO L.M.T.

Provider Business Mailing Address
First Line	:	PO BOX 558075
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33255-8075
Country	:	US
Telephone Number	:	305-790-2300
Fax Number	:

Provider Business Practice Location Address
First Line	:	5750 SW 42ND ST
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-5310
Country	:	US
Telephone Number	:	305-790-2300
Fax Number	:

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

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	09/09/2016

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