Provider Demographics
NPI:1700619368
Name:REEVES, SHIVAGO ANTIWAN
Entity type:Individual
Prefix:MR
First Name:SHIVAGO
Middle Name:ANTIWAN
Last Name:REEVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10750 PICTORIAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2567
Mailing Address - Country:US
Mailing Address - Phone:813-562-6774
Mailing Address - Fax:
Practice Address - Street 1:10750 PICTORIAL PARK DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2567
Practice Address - Country:US
Practice Address - Phone:813-562-6774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA100676225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist