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General NPI Number Information
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NPI Number | 1295045938
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Entity Type | Organization
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Legal Business Name | IBW GROUP, LLC
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Dates
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Enumeration Date | 10/15/2010
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Last Update Date | 10/15/2010
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Provider Practice Location Address
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Address Line | 272 SW ALACHUA AVE
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City | LAKE CITY
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State | FL
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Zip | 32025
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Country | US
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Telephone | 386-719-8887
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Fax | 386-719-6880
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Provider Business Mailing Address
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Address Line | PO BOX 2313
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City | LAKE CITY
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State | FL
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Zip | 32056
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Country | US
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Telephone | 386-719-8887
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Fax | 386-719-6880
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Authorized Official
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Title or Position | OWNER
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Name | BRIAN J LEWIS
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Credential | LMT
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Telephone | 386-719-8887
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA 60365
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License Number State | FL
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