Provider Demographics
NPI:1962881763
Name:PELUDAT, MELBA FAYE (MASSAGE THERAPIST)
Entity type:Individual
Prefix:
First Name:MELBA
Middle Name:FAYE
Last Name:PELUDAT
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 STATE ROAD 16
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5400
Mailing Address - Country:US
Mailing Address - Phone:904-655-3670
Mailing Address - Fax:
Practice Address - Street 1:2730 STATE ROAD 16
Practice Address - Street 2:SUITE 110
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5400
Practice Address - Country:US
Practice Address - Phone:904-655-3670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist