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NPI Code Detail

MEDICARE: JUDE REPAK LMT

MEDICARE: JUDE REPAK LMT
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
1225700000XMassage TherapistMT-22787AZ

General Provider Information

NPI Number : 1245782648
Entity Type Code : Individual
Provider Name (Legal Business Name) : JUDE REPAK LMT
Provider Business Mailing Address
First Line : 1590 WILLOW CREEK RD
Second Line :
City : PRESCOTT
State : AZ
Zip : 86301-1164
Country : US
Telephone Number : 928-227-1899
Fax Number : 800-536-1048
Provider Business Practice Location Address
First Line : 1590 WILLOW CREEK RD
Second Line :
City : PRESCOTT
State : AZ
Zip : 86301-1164
Country : US
Telephone Number : 928-227-1899
Fax Number : 800-536-1048
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/01/2016
Last Update Date : 11/01/2016

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