Provider Demographics
NPI:1598380263
Name:MAYORGA, PITER
Entity Type:Individual
Prefix:
First Name:PITER
Middle Name:
Last Name:MAYORGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PITER
Other - Middle Name:
Other - Last Name:MAYORGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:13817 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-7221
Mailing Address - Country:US
Mailing Address - Phone:305-366-3966
Mailing Address - Fax:
Practice Address - Street 1:13817 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-7221
Practice Address - Country:US
Practice Address - Phone:786-366-3966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA41754225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty