=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205792389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID GREENWALT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/01/2026
-----------------------------------------------------
Last Update Date | 01/01/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 914 N SAN FRANCISCO ST STE M
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-3254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-707-4070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5555 N WEATHERFORD RD
-----------------------------------------------------
City | FLAGSTAFF
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86001-7895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-707-4070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT-50575
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------