MEDICARE: GEORGE DOSDOS SACLA 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	MA 39398	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22231	OTHER		AUTOMOBILE ACCIDENT INSURANCE (PIP)
2	39398	OTHER	FL	BLUE CROSS AND BLUE SHIELD
3	22203	OTHER	FL	WORKERS COMP.

General Provider Information

NPI Number	:	1689818742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGE DOSDOS SACLA LMT

Provider Business Mailing Address
First Line	:	339 RACETRACK RD NW
Second Line	:	SUITE 12
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1538
Country	:	US
Telephone Number	:	850-368-3393
Fax Number	:	850-398-5923

Provider Business Practice Location Address
First Line	:	339 RACETRACK RD NW
Second Line	:	SUITE 12
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1538
Country	:	US
Telephone Number	:	850-368-3393
Fax Number	:	850-398-5923

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

Provider Enumeration Date	:	04/20/2009
Last Update Date	:	04/20/2009

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