Provider Demographics
NPI:1437283066
Name:NICOLOFF, VISVAMBHARA (LMT)
Entity Type:Individual
Prefix:MR
First Name:VISVAMBHARA
Middle Name:
Last Name:NICOLOFF
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 1:13700 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-8549
Mailing Address - Country:US
Mailing Address - Phone:386-418-3869
Mailing Address - Fax:386-418-3810
Practice Address - Street 1:13700 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-8549
Practice Address - Country:US
Practice Address - Phone:386-418-3869
Practice Address - Fax:386-418-3810
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 42906225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA42906OtherMASSAGE LICENSE