MEDICARE: EPIPHANY MASSAGE THERAPY, 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

General Provider Information

NPI Number	:	1326661596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EPIPHANY MASSAGE THERAPY, INC

Provider Business Mailing Address
First Line	:	303 E STROOP RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45429-2827
Country	:	US
Telephone Number	:	937-949-1144
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 E STROOP RD
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45429-2827
Country	:	US
Telephone Number	:	937-949-1144
Fax Number	:

Authorized Official
Title or Position	:	OWNER/LMT
Name	:	CARMEN ROCHELLE BOONE
Credential	:	LMT
Telephone Number	:	937-949-1144

Provider Enumeration Date	:	05/22/2020
Last Update Date	:	05/22/2020

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