Healthcare Provider Details

I. General information

NPI: 1417308917
Provider Name (Legal Business Name): AARON BUMPUS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 W 22ND ST 2
NEW YORK NY
10010-5805
US

IV. Provider business mailing address

6205 WOODHAVEN BLVD #2C
REGO PARK NY
11374-2769
US

V. Phone/Fax

Practice location:
  • Phone: 212-255-5488
  • Fax:
Mailing address:
  • Phone: 718-775-5249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number029419
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: