MEDICARE: MR. PABLO GONZALEZ SR. MASSAGE THERAPY

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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	MA64616	FL

General Provider Information

NPI Number	:	1194000745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PABLO GONZALEZ SR. MASSAGE THERAPY

Provider Business Mailing Address
First Line	:	2613 SW 143RD AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-6583
Country	:	US
Telephone Number	:	786-444-6695
Fax Number	:

Provider Business Practice Location Address
First Line	:	2613 SW 143RD AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33175-6583
Country	:	US
Telephone Number	:	786-444-6695
Fax Number	:

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

Provider Enumeration Date	:	10/14/2011
Last Update Date	:	10/14/2011

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