=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073062022
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SERENITY THERAPEUTIC MASSAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2016
-----------------------------------------------------
Last Update Date | 09/30/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 912 W MAIN ST STE 201
-----------------------------------------------------
City | NEW HOLLAND
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17557-9202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-466-9102
-----------------------------------------------------
Fax | 717-556-8818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 912 W MAIN ST STE 201
-----------------------------------------------------
City | NEW HOLLAND
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17557-9202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-466-9102
-----------------------------------------------------
Fax | 717-556-8818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASSAGE THERAPIST/ OWNER
-----------------------------------------------------
Name | IOANA J WEAVER
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 717-466-9102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MSG004082
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------