Provider Demographics
NPI:1730203340
Name:MONTANO, IDALMIS
Entity type:Individual
Prefix:
First Name:IDALMIS
Middle Name:
Last Name:MONTANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W OKALOOSA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-1025
Mailing Address - Country:US
Mailing Address - Phone:813-928-6380
Mailing Address - Fax:
Practice Address - Street 1:6632 HANLEY RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-4704
Practice Address - Country:US
Practice Address - Phone:813-884-5390
Practice Address - Fax:813-885-2958
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 39946225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist