Basic Information
| Provider Information | |||||||||
| NPI: | 1073761342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERISMA | ||||||||
| FirstName: | JOI | ||||||||
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| OtherLastName: | DERISMA | ||||||||
| OtherFirstName: | JOI | ||||||||
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| OtherCredential: | LMT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8912 W FLAGLER ST | ||||||||
| Address2: | #203 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331743950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549187180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5961 NW 173RD DR | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330155114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055567500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2008 | ||||||||
| LastUpdateDate: | 08/28/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA33160 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.