MEDICARE: MS. CRYSTAL MADONNA SPELLER 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	MA79922	FL

General Provider Information

NPI Number	:	1902420581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CRYSTAL MADONNA SPELLER LMT

Provider Business Mailing Address
First Line	:	1400 HAND AVE STE T
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-8196
Country	:	US
Telephone Number	:	386-451-8196
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 HAND AVE STE T
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-8196
Country	:	US
Telephone Number	:	386-451-8196
Fax Number	:

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

Provider Enumeration Date	:	05/30/2020
Last Update Date	:	05/30/2020

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