Provider Demographics
NPI:1811183353
Name:CARRUTH, JANIS E (LMT)
Entity type:Individual
Prefix:MS
First Name:JANIS
Middle Name:E
Last Name:CARRUTH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CEDAR BOUGH CT
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-6580
Mailing Address - Country:US
Mailing Address - Phone:904-471-7067
Mailing Address - Fax:
Practice Address - Street 1:2180 A1A S STE 204
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-6523
Practice Address - Country:US
Practice Address - Phone:904-806-2033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA34916174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA34916OtherFLORIDA BOARD OF MASSAGE
FLC1639OtherBLUE CROSS/BLUE SHIELD