MEDICARE: MASSAGE THERAPY CLINC

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	:	1841534526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MASSAGE THERAPY CLINC

Provider Business Mailing Address
First Line	:	6409 GEORGETOWN NORTH BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7007
Country	:	US
Telephone Number	:	260-492-9999
Fax Number	:	260-492-1105

Provider Business Practice Location Address
First Line	:	6409 GEORGETOWN NORTH BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7007
Country	:	US
Telephone Number	:	260-492-9999
Fax Number	:	260-969-1105

Authorized Official
Title or Position	:	CEO
Name	:	MRS. KATHLEEN SUE JALAE-BROWN
Credential	:
Telephone Number	:	260-492-9999

Provider Enumeration Date	:	11/19/2012
Last Update Date	:	11/19/2012

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