Healthcare Provider Details

I. General information

NPI: 1316308422
Provider Name (Legal Business Name): MAE MASSAGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2016
Last Update Date: 03/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15211 E 101ST WAY
COMMERCE CITY CO
80022-9741
US

IV. Provider business mailing address

15211 E 101ST WAY
COMMERCE CITY CO
80022-9741
US

V. Phone/Fax

Practice location:
  • Phone: 720-839-8937
  • Fax:
Mailing address:
  • Phone: 720-839-8937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number0013383
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0013383
License Number StateCO

VIII. Authorized Official

Name: MRS. AMANDA MAE WARD
Title or Position: CERTIFIED MASSAGE THERAPIST
Credential: CMT
Phone: 720-839-8937