=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285043034
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUR BODY SHOPPE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2014
-----------------------------------------------------
Last Update Date | 08/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12001 TEJON ST 122
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80234-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-412-7614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12001 TEJON ST 122
-----------------------------------------------------
City | WESTMINSTER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80234-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | ALISON STICKROD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 970-412-7614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 0002508
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------