Provider Demographics
NPI:1578995874
Name:YUDHA, BATARA (LMT)
Entity Type:Individual
Prefix:
First Name:BATARA
Middle Name:
Last Name:YUDHA
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 1:4701 88TH AVE N APT 805
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33782-5722
Mailing Address - Country:US
Mailing Address - Phone:850-319-5017
Mailing Address - Fax:
Practice Address - Street 1:400 CARILLON PKWY
Practice Address - Street 2:130
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1290
Practice Address - Country:US
Practice Address - Phone:727-202-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA73451225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist