Provider Demographics
NPI:1942469275
Name:NIDETZ, ANDREW (LMT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:NIDETZ
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 1:1301 NE MIAMI GARDENS DR APT 911
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-4982
Mailing Address - Country:US
Mailing Address - Phone:305-281-0331
Mailing Address - Fax:
Practice Address - Street 1:1301 NE MIAMI GARDENS DR APT 911
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-4982
Practice Address - Country:US
Practice Address - Phone:305-281-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA10269225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist