MEDICARE: SIMON ADVENTURES, 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	:	1366853517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIMON ADVENTURES, LLC

Provider Business Mailing Address
First Line	:	3881 ALTON PKWY
Second Line	:	SUITE A
City	:	IRVINE
State	:	CA
Zip	:	92606-8224
Country	:	US
Telephone Number	:	949-383-5388
Fax Number	:	949-783-0891

Provider Business Practice Location Address
First Line	:	19401 SAINT JUDE DR
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92705-1342
Country	:	US
Telephone Number	:	714-669-1470
Fax Number	:	714-669-8153

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MITCHELL D SIMON
Credential	:
Telephone Number	:	714-920-5777

Provider Enumeration Date	:	05/09/2014
Last Update Date	:	05/09/2014

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