Provider Demographics
NPI:1700027984
Name:DIVERSIFIED THERAPEUTICS INC
Entity Type:Organization
Organization Name:DIVERSIFIED THERAPEUTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/LICENSED MASSAGE THERAPIS
Authorized Official - Prefix:MR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT, CPT
Authorized Official - Phone:772-221-7638
Mailing Address - Street 1:613 SE CENTRAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994
Mailing Address - Country:US
Mailing Address - Phone:772-221-7638
Mailing Address - Fax:772-221-7628
Practice Address - Street 1:613 SE CENTRAL PARKWAY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994
Practice Address - Country:US
Practice Address - Phone:772-221-7638
Practice Address - Fax:772-221-7628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0018459225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC8068OtherBLUE CROSS BLUE SHIELD