=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205303575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAVAJO MASSAGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2018
-----------------------------------------------------
Last Update Date | 10/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HALCHITA HOUSING 1
-----------------------------------------------------
City | MEXICAN HAT
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-874-7488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 310130
-----------------------------------------------------
City | MEXICAN HAT
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84531-0130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KARLENA SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-874-7488
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------