Provider Demographics
NPI:1538395116
Name:RIESMEYER, MICHAEL WILLIAM (LMT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:RIESMEYER
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 1:1361 13TH AVE S
Mailing Address - Street 2:SUITE 210
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3233
Mailing Address - Country:US
Mailing Address - Phone:904-247-8187
Mailing Address - Fax:904-247-8147
Practice Address - Street 1:1361 13TH AVE S
Practice Address - Street 2:SUITE 210
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3233
Practice Address - Country:US
Practice Address - Phone:904-247-8187
Practice Address - Fax:904-247-8147
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0019428225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC8302OtherBLUE CROSS & BLUE SHIELD