=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407107360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASPEN MEDICAL MASSAGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2012
-----------------------------------------------------
Last Update Date | 09/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1030 JOHNSON ROAD SUITE 282
-----------------------------------------------------
City | GOLDEN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-290-3545
-----------------------------------------------------
Fax | 303-278-2612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1030 JOHNSON ROAD SUITE 282
-----------------------------------------------------
City | GOLDEN
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 970-290-3545
-----------------------------------------------------
Fax | 303-278-2612
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MASSAGE THERAPIST
-----------------------------------------------------
Name | MRS. MICHELLE L GOYMERAC
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 970-290-3545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 664
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------