Organization
MASSAGE THERAPY SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. THOMAS JOSEPH FASONE LMT (OWNER)
(386) 258-7900
Entity
Organization
Contact information
Practice address
290 CLYDE MORRIS BLVD, ORMOND BEACH, FL 32174-8130
(386) 258-7900
(386) 898-0459
Mailing address
PO BOX 730354, ORMOND BEACH, FL 32173-0354
(386) 258-7900
(386) 898-0459
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
MA-14579
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C-5306
BLUE CROSS BLUE SHIELD
FL
Enumeration date
12/13/2011
Last updated
12/13/2011
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