Provider Demographics
NPI:1780959403
Name:MACIAS, LUIS Y
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:Y
Last Name:MACIAS
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 1:2440 HUNTER TER
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7327
Mailing Address - Country:US
Mailing Address - Phone:786-260-4903
Mailing Address - Fax:
Practice Address - Street 1:2440 HUNTER TER
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7327
Practice Address - Country:US
Practice Address - Phone:786-260-4903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM220-539-74-066-0172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist