Provider Demographics
NPI:1790831204
Name:CANDELORA, JUSTIN (NCTMB MASSAGE THERAI)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:CANDELORA
Suffix:
Gender:M
Credentials:NCTMB MASSAGE THERAI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32805-4425
Mailing Address - Country:US
Mailing Address - Phone:407-616-4756
Mailing Address - Fax:
Practice Address - Street 1:604 FRONT ST
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4675
Practice Address - Country:US
Practice Address - Phone:321-939-2328
Practice Address - Fax:321-939-2033
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA47129111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation