Individual
MICHAEL ANANTA ROSIDIVITO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LMT
Contact information
Practice address
2200 ATLANTA RD SE APT I3, SMYRNA, GA 30080-1538
(609) 314-1254
Mailing address
2200 ATLANTA RD SE APT I3, SMYRNA, GA 30080-1538
(160) 931-4125
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
MT011960
GA
Other
Enumeration date
04/24/2022
Last updated
04/24/2022
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