=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245777564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGIA HEISSER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2017
-----------------------------------------------------
Last Update Date | 01/24/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7750 PARK NORTH DR
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77708-2425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-849-8298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 21285
-----------------------------------------------------
City | BEAUMONT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77720-1285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MASSAGE THERAPIST
-----------------------------------------------------
Name | MS. GEORGIA HEISSER
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 832-849-8298
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | MT126192
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------