MEDICARE: MISS FERN HARRIS MASSAGE THERAPIST

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	MA58946	FL

General Provider Information

NPI Number	:	1417221904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS FERN HARRIS MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	2798 SE MARIPOSA AVE
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-7271
Country	:	US
Telephone Number	:	772-626-9997
Fax Number	:

Provider Business Practice Location Address
First Line	:	1981 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-5555
Country	:	US
Telephone Number	:	772-626-9997
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/29/2012
Last Update Date	:	02/29/2012

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