Provider Demographics
NPI:1396944005
Name:ANDERSON, ERIC B (LMT)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:B
Last Name:ANDERSON
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 1:488 N CAUSEWAY
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32169-5234
Mailing Address - Country:US
Mailing Address - Phone:386-427-5837
Mailing Address - Fax:
Practice Address - Street 1:488 N CAUSEWAY
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32169-5234
Practice Address - Country:US
Practice Address - Phone:386-427-5837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0010485225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC7803OtherBCBS
FLMA0010485OtherCOMMERCIAL