Provider Demographics
NPI:1134975246
Name:TOMILKO, TAISIYA
Entity type:Individual
Prefix:
First Name:TAISIYA
Middle Name:
Last Name:TOMILKO
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 1:20 N ASPEN PT
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34461-7004
Mailing Address - Country:US
Mailing Address - Phone:352-227-0186
Mailing Address - Fax:
Practice Address - Street 1:1487 W PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3165
Practice Address - Country:US
Practice Address - Phone:352-227-0186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA94081225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist