=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124359245
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVE OLDENHAGE MASSAGE & BODYWORK, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2010
-----------------------------------------------------
Last Update Date | 01/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 180 PHILLIPS HILL RD BUILDING 1
-----------------------------------------------------
City | NEW CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10956-4132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-634-8822
-----------------------------------------------------
Fax | 845-634-8823
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 180 PHILLIPS HILL RD BUILDING 1
-----------------------------------------------------
City | NEW CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10956-4132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-634-8822
-----------------------------------------------------
Fax | 845-634-8823
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVE OLDENHAGE
-----------------------------------------------------
Credential | BS, LMT, NCBTMB
-----------------------------------------------------
Telephone | 845-634-8822
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 022500
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------