MEDICARE: JAKKI BOSCO 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	MA45584	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C4124	OTHER	FL	BCBSF PROVIDER NUMBER

General Provider Information

NPI Number	:	1366509754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAKKI BOSCO LMT

Provider Business Mailing Address
First Line	:	1710 ESCORT AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33610-3451
Country	:	US
Telephone Number	:	813-298-5603
Fax Number	:

Provider Business Practice Location Address
First Line	:	3910 NORTHDALE BLVD
Second Line	:	SUITE 208
City	:	TAMPA
State	:	FL
Zip	:	33624-1800
Country	:	US
Telephone Number	:	813-298-5603
Fax Number	:

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

Provider Enumeration Date	:	01/03/2007
Last Update Date	:	07/08/2007

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