=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215602065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOLE'RENITY SPA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2021
-----------------------------------------------------
Last Update Date | 08/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 W 1ST ST
-----------------------------------------------------
City | SULPHUR
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73086-4818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-622-8128
-----------------------------------------------------
Fax | 580-622-6350
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 711
-----------------------------------------------------
City | SULPHUR
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73086-0711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-736-5054
-----------------------------------------------------
Fax | 580-622-6350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DIRECTOR
-----------------------------------------------------
Name | RHONDA CAROL PITMON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 940-736-5054
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------