MEDICARE: DAVID AYALA 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	MA96368	FL

General Provider Information

NPI Number	:	1336736172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID AYALA LMT

Provider Business Mailing Address
First Line	:	5616 NW WHITECAP RD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-3619
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5616 NW WHITECAP RD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-3619
Country	:	US
Telephone Number	:	407-455-1677
Fax Number	:

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

Provider Enumeration Date	:	12/28/2020
Last Update Date	:	12/28/2020

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