Provider Demographics
NPI:1548301245
Name:JOHN STEPHENS
Entity type:Organization
Organization Name:JOHN STEPHENS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:BA, LMT
Authorized Official - Phone:321-783-5592
Mailing Address - Street 1:49 S ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-2713
Mailing Address - Country:US
Mailing Address - Phone:321-783-5592
Mailing Address - Fax:321-783-0558
Practice Address - Street 1:49 S ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-2713
Practice Address - Country:US
Practice Address - Phone:321-783-5592
Practice Address - Fax:321-783-0558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP2085171100000X
FLMM9078225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMM9078OtherFL MASSAGE ESTAB NUMBER
FLMM9078OtherFL MASSAGE ESTAB NUMBER