Provider Demographics
NPI:1114246915
Name:ROSA, NELSON (LMT)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:ROSA
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 1:8180 NW 36TH ST
Mailing Address - Street 2:SUITE 418
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6645
Mailing Address - Country:US
Mailing Address - Phone:305-482-0251
Mailing Address - Fax:305-482-0257
Practice Address - Street 1:8180 NW 36TH ST
Practice Address - Street 2:SUITE 418
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6645
Practice Address - Country:US
Practice Address - Phone:305-482-0251
Practice Address - Fax:305-482-0257
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA53585225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist