=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336625649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASSAGE BY VICKIE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2018
-----------------------------------------------------
Last Update Date | 07/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1055 PINEY FOREST RD STE A
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24540-1531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-250-6932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1055 PINEY FOREST RD STE A
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24540-1531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-250-6932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VICKIE WOODS PRITCHETT
-----------------------------------------------------
Credential | CMT
-----------------------------------------------------
Telephone | 434-250-6932
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 001900-6751
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------