=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336536614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 7 WELLNESS & MASSAGE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2015
-----------------------------------------------------
Last Update Date | 10/11/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1925 GRAND AVE SUITE 134
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-2764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-696-3908
-----------------------------------------------------
Fax | 406-252-3171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1925 GRAND AVE SUITE 134
-----------------------------------------------------
City | BILLINGS
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59102-2764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-696-3908
-----------------------------------------------------
Fax | 406-252-3171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MASSAGE THERAPIST
-----------------------------------------------------
Name | MS. MARYAH JACKSON
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 406-696-3908
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 5952
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------