=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043792658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA LUCAN LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2018
-----------------------------------------------------
Last Update Date | 08/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 E 58TH ST STE 809
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10022-1128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-872-2865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 E 119TH ST APT 4C
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10035-4287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-872-2865
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 020539-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------