Provider Demographics
NPI:1356588909
Name:MAMUYAC, BERNARD HABALUYAS (LMT)
Entity type:Individual
Prefix:
First Name:BERNARD
Middle Name:HABALUYAS
Last Name:MAMUYAC
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 1:1286 SW AVENS ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2506
Mailing Address - Country:US
Mailing Address - Phone:772-321-9185
Mailing Address - Fax:772-785-9094
Practice Address - Street 1:1286 SW AVENS ST
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-2506
Practice Address - Country:US
Practice Address - Phone:772-321-9185
Practice Address - Fax:772-785-9094
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-17
Last Update Date:2009-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA50322225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist