Provider Demographics
NPI:1790449221
Name:CARVALHO, GEORGE IVAN (LMT)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:IVAN
Last Name:CARVALHO
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 1:435 LAKEVIEW DR APT 101
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-2447
Mailing Address - Country:US
Mailing Address - Phone:786-315-6602
Mailing Address - Fax:
Practice Address - Street 1:435 LAKEVIEW DR APT 101
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-2447
Practice Address - Country:US
Practice Address - Phone:786-315-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA90950225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist