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General NPI Number Information
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NPI Number | 1134647456
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Entity Type | Organization
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Legal Business Name | MATRIX MYOFASCIAL
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Dates
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Enumeration Date | 09/07/2017
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Last Update Date | 09/07/2017
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Provider Practice Location Address
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Address Line | 187 RUSSELL ST
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City | HADLEY
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State | MA
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Zip | 01035-9521
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Country | US
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Telephone | 413-522-0658
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Fax |
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Provider Business Mailing Address
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Address Line | 678 BERNARDSTON RD
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City | GREENFIELD
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State | MA
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Zip | 01301-1104
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Country | US
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Telephone | 413-522-0658
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Fax |
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Authorized Official
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Title or Position | CHIEF THERAPIST & CLINICAL DIRECTOR
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Name | MR. THEODORE NATHANIEL MOSER
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Credential | LMT, CPMT II, CIMT
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Telephone | 413-522-0658
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 9911-MT-MT
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License Number State | MA
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