=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184465684
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLOOM HOLISTIC BODYWORK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2024
-----------------------------------------------------
Last Update Date | 06/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 JONES FRANKLIN RD
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27606-5440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-780-4188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 OPEN FIELD DR
-----------------------------------------------------
City | GARNER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27529-6809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-780-4188
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASSAGE THERAPIST
-----------------------------------------------------
Name | MRS. ERIN M BENSON
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 919-780-4188
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------