Healthcare Provider Details

I. General information

NPI: 1174061683
Provider Name (Legal Business Name): MASSAGE AND FITNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 EAST AVE SUITE 310
NORWALK CT
06851-4902
US

IV. Provider business mailing address

83 EAST AVE SUITE 310
NORWALK CT
06851-4902
US

V. Phone/Fax

Practice location:
  • Phone: 203-939-9319
  • Fax:
Mailing address:
  • Phone: 203-939-9319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberT58152
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: PATRICK BOYER
Title or Position: OWNER
Credential:
Phone: 203-939-9319