MEDICARE: LISA MATULKA MA83905

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	MA83905	FL

General Provider Information

NPI Number	:	1538632062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MATULKA MA83905

Provider Business Mailing Address
First Line	:	6020 JONATHANS BAY CIR APT 301
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-7255
Country	:	US
Telephone Number	:	704-860-4959
Fax Number	:

Provider Business Practice Location Address
First Line	:	3411 BONITA BEACH RD STE 305
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-4155
Country	:	US
Telephone Number	:	239-529-7122
Fax Number	:

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

Provider Enumeration Date	:	01/08/2019
Last Update Date	:	01/08/2019

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