Organization
DIVERSIFIED THERAPEUTICS INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CALVIN LEE JACKSON LMT, CPT (PRESIDENT/LICENSED MASSAGE THERAPIS)
(772) 221-7638
Entity
Organization
Contact information
Practice address
613 SE CENTRAL PARKWAY, STUART, FL 34994
(772) 221-7638
(772) 221-7628
Mailing address
613 SE CENTRAL PARKWAY, STUART, FL 34994
(772) 221-7638
(772) 221-7628
Taxonomy
Speciality
Code
Description
License number
State
225700000X
Massage Therapist
Primary
MA0018459
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C8068
BLUE CROSS BLUE SHIELD
FL
Enumeration date
03/17/2009
Last updated
03/17/2009
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