Provider Demographics
NPI:1003180951
Name:MACEDONIO, ALFONSO (LMT)
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:MACEDONIO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 21ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-5535
Mailing Address - Country:US
Mailing Address - Phone:813-359-3657
Mailing Address - Fax:
Practice Address - Street 1:4423 PARK BLVD N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-3540
Practice Address - Country:US
Practice Address - Phone:727-827-2825
Practice Address - Fax:727-827-2809
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 59142225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist