=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003532037
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING WELL WNY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2022
-----------------------------------------------------
Last Update Date | 10/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3281 TRANSIT RD
-----------------------------------------------------
City | ELMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14059-9637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-656-7600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3281 TRANSIT RD
-----------------------------------------------------
City | ELMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14059-9637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-656-7600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-PRESIDEN
-----------------------------------------------------
Name | MRS. JILL NICOLE MAZUR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-656-7600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------