=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275806812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHIRLEY A. CONRAD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2012
-----------------------------------------------------
Last Update Date | 02/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4211 NORTH BUFFALO STREET
-----------------------------------------------------
City | ORCHARD PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-866-2826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 RAMONA AVENUE
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14220-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-866-2826
-----------------------------------------------------
Fax | 716-825-1994
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SHIRLEY A. CONRAD
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 716-866-2826
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 014646-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------