Healthcare Provider Details

I. General information

NPI: 1386810034
Provider Name (Legal Business Name): JACKPOT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2008
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 S CASCO VILLAGE RD
CASCO ME
04015-4246
US

IV. Provider business mailing address

5 S CASCO VILLAGE RD
CASCO ME
04015-4246
US

V. Phone/Fax

Practice location:
  • Phone: 207-655-2520
  • Fax:
Mailing address:
  • Phone: 207-655-2520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT2492
License Number StateME

VIII. Authorized Official

Name: MRS. LORI ANN SHAW
Title or Position: COORDINATOR
Credential: L.M.T.
Phone: 207-655-2520