=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073042586
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HANNAH N MUTH LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2017
-----------------------------------------------------
Last Update Date | 06/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 N 9TH ST
-----------------------------------------------------
City | ROCKY FORD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81067-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-469-3443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22713 HWY 10
-----------------------------------------------------
City | LA JUNTA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 0018377
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------