=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073759973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLU SPA AND SALON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2008
-----------------------------------------------------
Last Update Date | 12/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3030 ORCHARD PARK RD
-----------------------------------------------------
City | WEST SENECA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14224-4638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-675-2258
-----------------------------------------------------
Fax | 716-675-2250
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3030 ORCHARD PARK RD
-----------------------------------------------------
City | WEST SENECA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14224-4638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-675-2258
-----------------------------------------------------
Fax | 716-675-2250
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPA OWNER
-----------------------------------------------------
Name | MRS. VICKI KEHR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-672-2258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------