MEDICARE: EDEN MASSAGE & SPA, INC

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	LIC #19555	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	686157196	OTHER	FL	MED WAIVER

General Provider Information

NPI Number	:	1194982140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDEN MASSAGE & SPA, INC

Provider Business Mailing Address
First Line	:	2655 E OAKLAND PARK BLVD
Second Line	:	SUITE #2
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1608
Country	:	US
Telephone Number	:	954-564-9536
Fax Number	:	954-565-2910

Provider Business Practice Location Address
First Line	:	2655 E OAKLAND PARK BLVD
Second Line	:	SUITE #2
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1608
Country	:	US
Telephone Number	:	954-564-9536
Fax Number	:	954-565-2910

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MS. GRACE OKON PAUL
Credential	:	LMT
Telephone Number	:	954-564-9536

Provider Enumeration Date	:	05/19/2008
Last Update Date	:	05/19/2008

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