=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265141154
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. TIFFANY SARAH CAGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2022
-----------------------------------------------------
Last Update Date | 11/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 850 W IRONWOOD DR STE 104
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83814-4903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-664-5225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 W MULBERRY LN
-----------------------------------------------------
City | COEUR D ALENE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83815-7967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 288-916-6364
-----------------------------------------------------
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 | MAS-2726
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------