=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124149042
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ITS ALL ABOUT YOU MASSAGE AND DAY SPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 RACETRACK RD NW
-----------------------------------------------------
City | FORT WALTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32547-4612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-314-6642
-----------------------------------------------------
Fax | 850-609-1796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 ELKWOOD CT
-----------------------------------------------------
City | SHALIMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32579-2207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-314-6642
-----------------------------------------------------
Fax | 850-609-1796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MASSAGE THERAPIST OWNER
-----------------------------------------------------
Name | DENISE WILLLIAMS
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 850-314-6642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MM15298
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------