=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427412634
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASSAGE SUPREME THERAPEUTIC AND WELLNESS SPA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2016
-----------------------------------------------------
Last Update Date | 04/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2168 MILLBURN AVE SUITE 205
-----------------------------------------------------
City | MAPLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07040-2640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-444-0040
-----------------------------------------------------
Fax | 973-843-7129
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 183A COURT ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07103-3824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-444-0040
-----------------------------------------------------
Fax | 973-843-7129
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SEGILADE JOBIODENEYE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-444-0040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 18KT00182400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------