Provider Demographics
NPI:1396497004
Name:DE HEUSCH LARA, MELODY (DC)
Entity type:Individual
Prefix:DR
First Name:MELODY
Middle Name:
Last Name:DE HEUSCH LARA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 NW 43RD AVE APT 640
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4147
Mailing Address - Country:US
Mailing Address - Phone:787-464-3113
Mailing Address - Fax:
Practice Address - Street 1:811 NW 43RD AVE APT 640
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-4147
Practice Address - Country:US
Practice Address - Phone:787-464-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13901111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor