=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073069191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MA' THERAPY (MASSAGE SPA CLINIC)
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2016
-----------------------------------------------------
Last Update Date | 09/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 TWIN OAKS DR 101
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32506-6637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-426-4158
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4600 TWIN OAKS DR 101
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32506-6637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-426-4158
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ L.M.T.
-----------------------------------------------------
Name | TAMALA A ALLEN
-----------------------------------------------------
Credential | L.M.T.
-----------------------------------------------------
Telephone | 850-426-4158
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | MA 62968
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------