Provider Demographics
NPI:1174681175
Name:VIDAL, JANICE L (LMT)
Entity Type:Individual
Prefix:MS
First Name:JANICE
Middle Name:L
Last Name:VIDAL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:897 N HOLLYWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-2644
Mailing Address - Country:US
Mailing Address - Phone:352-795-3191
Mailing Address - Fax:352-795-3191
Practice Address - Street 1:4027 N LECANTO HWY
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3551
Practice Address - Country:US
Practice Address - Phone:352-527-2515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA#43019225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA#43019OtherMASSAGE LICENSE
FLC2917OtherBCBS PROVIDER NUMBER