Provider Demographics
NPI:1578006706
Name:BISACCHI, LUIZ AUGUSTO (LMT)
Entity Type:Individual
Prefix:
First Name:LUIZ AUGUSTO
Middle Name:
Last Name:BISACCHI
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 1:12102 CHESTER TERRACE CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2698
Mailing Address - Country:US
Mailing Address - Phone:813-361-1538
Mailing Address - Fax:
Practice Address - Street 1:12102 CHESTER TERRACE CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-2698
Practice Address - Country:US
Practice Address - Phone:813-361-1538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-19
Last Update Date:2016-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA83274225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist