MEDICARE: MRS. CHANDRA ENRIGHT-WALLACE LMT, NCBTMB

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	12775	CO

General Provider Information

NPI Number	:	1952705998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHANDRA ENRIGHT-WALLACE LMT, NCBTMB

Provider Business Mailing Address
First Line	:	102 S TEJON ST
Second Line	:	SUITE 102A
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-2231
Country	:	US
Telephone Number	:	719-784-3330
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 S TEJON ST
Second Line	:	SUITE 102A
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-2231
Country	:	US
Telephone Number	:	719-784-3330
Fax Number	:

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

Provider Enumeration Date	:	10/20/2014
Last Update Date	:	03/17/2016

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