Basic Information
| Provider Information | |||||||||
| NPI: | 1003149709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOMFORT | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMT,HMLDT,COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 663 SE 19TH ST | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344715324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528047617 | ||||||||
| FaxNumber: | 3526226100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1328 SE 25TH LOOP | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344711026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3528047617 | ||||||||
| FaxNumber: | 3526226100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2009 | ||||||||
| LastUpdateDate: | 09/12/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA53889 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.