Provider Demographics
NPI:1093582165
Name:LOOS, MYKA
Entity Type:Individual
Prefix:
First Name:MYKA
Middle Name:
Last Name:LOOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S MARION AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-7065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:415 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5270
Practice Address - Country:US
Practice Address - Phone:386-209-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA91173225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist