=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144045261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMASSAGEMED LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2024
-----------------------------------------------------
Last Update Date | 11/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 SE 6TH AVE STE 200
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33483-5306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-760-1232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11211 S MILITARY TRL APT 614
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33436-7229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-612-3761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | IOSIF YUABOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-760-1232
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------