Provider Demographics
NPI:1770192064
Name:VICOS, SOPHIA FAY
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:FAY
Last Name:VICOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 6TH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3255
Mailing Address - Country:US
Mailing Address - Phone:321-409-8808
Mailing Address - Fax:
Practice Address - Street 1:114 6TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3255
Practice Address - Country:US
Practice Address - Phone:321-409-8808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA81204225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist