=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104299775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELAINE NAOMI BOUCHARD CMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2015
-----------------------------------------------------
Last Update Date | 11/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2414 21ST ST
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95818-2410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-388-0615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9437 FORT WORTH WAY
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95827-1013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-388-0615
-----------------------------------------------------
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 | 36438
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------