Provider Demographics
NPI:1952503500
Name:LANE, KEVIN JAMES (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:LANE
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3260 W HILLSBOROUGH AVE
Mailing Address - Street 2:# 111
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-5902
Mailing Address - Country:US
Mailing Address - Phone:813-873-9369
Mailing Address - Fax:813-873-9386
Practice Address - Street 1:3260 W HILLSBOROUGH AVE
Practice Address - Street 2:# 111
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-5902
Practice Address - Country:US
Practice Address - Phone:813-873-9369
Practice Address - Fax:813-873-9386
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 31627173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA 31627OtherLICENSE NO.