=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114560158
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA TOMS LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2019
-----------------------------------------------------
Last Update Date | 10/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5529 N RHETT AVE
-----------------------------------------------------
City | NORTH CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29406-3507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-256-3448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5715 ROBINSON ST
-----------------------------------------------------
City | HANAHAN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29410-3144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-473-0239
-----------------------------------------------------
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 | 11784
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------