Provider Demographics
NPI:1508195827
Name:MAIR, CAVAN
Entity Type:Individual
Prefix:
First Name:CAVAN
Middle Name:
Last Name:MAIR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 THIRD AVE SW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548
Mailing Address - Country:US
Mailing Address - Phone:352-538-7841
Mailing Address - Fax:
Practice Address - Street 1:128 EGLIN PKWY NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4917
Practice Address - Country:US
Practice Address - Phone:850-864-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA57810225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist