MEDICARE: INTERVENTION MASSAGE, LLC

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

General Provider Information

NPI Number	:	1164002556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERVENTION MASSAGE, LLC

Provider Business Mailing Address
First Line	:	425 AVALON PARK SOUTH BLVD STE 600
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-6702
Country	:	US
Telephone Number	:	407-202-9195
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 AVALON PARK SOUTH BLVD STE 600
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-6702
Country	:	US
Telephone Number	:	407-202-9195
Fax Number	:

Authorized Official
Title or Position	:	MANAGING OWNER
Name	:	MR. THOMAS GEORGE BUCK
Credential	:	LMT: MA94750
Telephone Number	:	407-202-9195

Provider Enumeration Date	:	04/10/2021
Last Update Date	:	04/10/2021

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