MEDICARE: SMITH MASSAGE THERAPY

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	52936	CA

General Provider Information

NPI Number	:	1629476528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMITH MASSAGE THERAPY

Provider Business Mailing Address
First Line	:	191 SAND CREEK RD
Second Line	:	SUITE 202-B
City	:	BRENTWOOD
State	:	CA
Zip	:	94513-2215
Country	:	US
Telephone Number	:	925-812-0344
Fax Number	:

Provider Business Practice Location Address
First Line	:	191 SAND CREEK RD
Second Line	:	SUITE 202-B
City	:	BRENTWOOD
State	:	CA
Zip	:	94513-2215
Country	:	US
Telephone Number	:	925-812-0344
Fax Number	:

Authorized Official
Title or Position	:	CERTIFIED MASSAGE THERAPIST
Name	:	MR. LOUIS E SMITH
Credential	:	CMT
Telephone Number	:	925-812-0344

Provider Enumeration Date	:	12/09/2014
Last Update Date	:	12/09/2014

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