Provider Demographics
NPI:1215296090
Name:MILLER, AJAYI (LMT)
Entity type:Individual
Prefix:
First Name:AJAYI
Middle Name:
Last Name:MILLER
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 1:1435 W BUSCH BLVD
Mailing Address - Street 2:STE 201 A
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-7621
Mailing Address - Country:US
Mailing Address - Phone:813-473-2744
Mailing Address - Fax:813-434-1624
Practice Address - Street 1:1435 W BUSCH BLVD
Practice Address - Street 2:STE 201 A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-7621
Practice Address - Country:US
Practice Address - Phone:813-473-2744
Practice Address - Fax:813-434-1624
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 68053225700000X
FL15904372600000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006109200Medicaid