Provider Demographics
NPI:1104209410
Name:DEPASS, DESMOND (LMT)
Entity Type:Individual
Prefix:MR
First Name:DESMOND
Middle Name:
Last Name:DEPASS
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 1:16951 SW 63RD MNR
Mailing Address - Street 2:
Mailing Address - City:SOUTHWEST RANCHES
Mailing Address - State:FL
Mailing Address - Zip Code:33331
Mailing Address - Country:US
Mailing Address - Phone:954-471-7950
Mailing Address - Fax:
Practice Address - Street 1:4621 N UNIVERSITY DR.
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067
Practice Address - Country:US
Practice Address - Phone:954-471-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-06
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA78630225700000X, 363AM0700X, 111NX0800X
133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical