Provider Demographics
NPI:1114136009
Name:RENGIFO, MARIELLA (LICENSED MASSAGE THE)
Entity Type:Individual
Prefix:MRS
First Name:MARIELLA
Middle Name:
Last Name:RENGIFO
Suffix:
Gender:F
Credentials:LICENSED MASSAGE THE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 N UNIVERSITY DR
Mailing Address - Street 2:APARTMENT 307
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351
Mailing Address - Country:US
Mailing Address - Phone:954-854-0974
Mailing Address - Fax:
Practice Address - Street 1:1852 N NOB HILL RD
Practice Address - Street 2:HOLISTIC MASSAGE & WELLNESS CLINICS
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33322-6548
Practice Address - Country:US
Practice Address - Phone:954-476-6401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 26202225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist