MEDICARE: MRS. MARIELLA RENGIFO LICENSED MASSAGE THE

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	MA 26202	FL

General Provider Information

NPI Number	:	1114136009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIELLA RENGIFO LICENSED MASSAGE THE

Provider Business Mailing Address
First Line	:	4205 N UNIVERSITY DR
Second Line	:	APARTMENT 307
City	:	SUNRISE
State	:	FL
Zip	:	33351
Country	:	US
Telephone Number	:	954-854-0974
Fax Number	:

Provider Business Practice Location Address
First Line	:	1852 N NOB HILL RD
Second Line	:	HOLISTIC MASSAGE & WELLNESS CLINICS
City	:	PLANTATION
State	:	FL
Zip	:	33322-6548
Country	:	US
Telephone Number	:	954-476-6401
Fax Number	:

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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