MEDICARE: SANDRA EUGENIA WALLACE 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	016400	TX

General Provider Information

NPI Number	:	1518153295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA EUGENIA WALLACE MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	3627 ACORNRUN LN
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77389-4721
Country	:	US
Telephone Number	:	281-651-7716
Fax Number	:

Provider Business Practice Location Address
First Line	:	3627 ACORNRUN LN
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77389-4721
Country	:	US
Telephone Number	:	281-651-7716
Fax Number	:

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

Provider Enumeration Date	:	09/17/2007
Last Update Date	:	09/17/2007

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