Provider Demographics
NPI:1952429771
Name:THOMAS, VINCENT (LMT)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:THOMAS
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:PO BOX 534
Mailing Address - Street 2:
Mailing Address - City:NEW SMYRNA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32170-0534
Mailing Address - Country:US
Mailing Address - Phone:386-427-4743
Mailing Address - Fax:386-427-5245
Practice Address - Street 1:812 W INDIAN RIVER BLVD
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32132-3429
Practice Address - Country:US
Practice Address - Phone:386-427-4743
Practice Address - Fax:386-427-5245
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA40685225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA40685OtherSTATE LICENSE
FLC2872OtherBLUE CROSS BLUE SHIELD