=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245433309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REID WILLIAM SALON & DAY SPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 FOREST AVE STE 4
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-1521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-772-1772
-----------------------------------------------------
Fax | 207-772-1744
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 FOREST AVE STE 4
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04101-1521
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-772-1772
-----------------------------------------------------
Fax | 207-772-1744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LAURIE THERIAULT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 207-772-1772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | ES35682
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------