=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366965683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL MASSAGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2017
-----------------------------------------------------
Last Update Date | 12/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2010 21ST ST
-----------------------------------------------------
City | GREELEY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80631-6807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-330-9320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2010 21ST ST
-----------------------------------------------------
City | GREELEY
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80631-6807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-330-9320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/OWNER
-----------------------------------------------------
Name | MAKI WADA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-330-9320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------