=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215608906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEOFFREY FRANCIS DJOMOAH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2021
-----------------------------------------------------
Last Update Date | 09/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1350 SE MAYNARD RD STE 104
-----------------------------------------------------
City | CARY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27511-3634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-899-0960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6210 CANARY FALLS LN APT 303
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27606-5851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-899-0960
-----------------------------------------------------
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 | 16317
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------