Healthcare Provider Details

I. General information

NPI: 1982479788
Provider Name (Legal Business Name): LISA BORTON MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4606 W JEFFERSON BLVD
FORT WAYNE IN
46804-6826
US

IV. Provider business mailing address

4606 W JEFFERSON BLVD
FORT WAYNE IN
46804-6826
US

V. Phone/Fax

Practice location:
  • Phone: 260-459-1111
  • Fax: 260-459-2209
Mailing address:
  • Phone: 260-459-1111
  • Fax: 260-459-2209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT21304797
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: