MEDICARE: JENNY MARIE RAETY LMT-CMMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	556	NV

General Provider Information

NPI Number	:	1003253501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNY MARIE RAETY LMT-CMMP

Provider Business Mailing Address
First Line	:	5415 W. HARMON AVE.
Second Line	:	UNIT# 1191
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-7046
Country	:	US
Telephone Number	:	702-460-3212
Fax Number	:

Provider Business Practice Location Address
First Line	:	5415 W. HARMON AVE.
Second Line	:	UNIT# 1191
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-7046
Country	:	US
Telephone Number	:	702-460-3212
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2013
Last Update Date	:	05/24/2013

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