=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265926695
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC BRAHA LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2018
-----------------------------------------------------
Last Update Date | 06/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 E BROADWAY RD STE 21
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-370-7336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6975 E PRINCESS DR APT 2059
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85054-4220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-370-7336
-----------------------------------------------------
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 | MT-02202P
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------