MEDICARE: STACIE REENA DEOSARAN LMT

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	MA73975	FL

General Provider Information

NPI Number	:	1326558826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACIE REENA DEOSARAN LMT

Provider Business Mailing Address
First Line	:	5475 VINELAND RD APT 8107
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32811-7635
Country	:	US
Telephone Number	:	407-932-8959
Fax Number	:

Provider Business Practice Location Address
First Line	:	5475 VINELAND RD APT 8107
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32811-7635
Country	:	US
Telephone Number	:	407-932-8959
Fax Number	:

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

Provider Enumeration Date	:	10/10/2017
Last Update Date	:	10/10/2017

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