MEDICARE: DIANE KINGSLEY RD

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	MA 50325	FL
2	133V00000X	Registered Dietitian	ND7147	FL

General Provider Information

NPI Number	:	1609133230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE KINGSLEY RD

Provider Business Mailing Address
First Line	:	333 17TH ST STE W
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-5687
Country	:	US
Telephone Number	:	772-538-2960
Fax Number	:	772-800-1050

Provider Business Practice Location Address
First Line	:	333 17TH ST STE W
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-5687
Country	:	US
Telephone Number	:	772-538-2960
Fax Number	:	772-800-1050

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

Provider Enumeration Date	:	04/20/2012
Last Update Date	:	09/28/2023

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Directions to “ DIANE KINGSLEY RD” Practice Location

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