=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427757723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKIN REVIVE MASSAGE AND SPA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2023
-----------------------------------------------------
Last Update Date | 02/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13453 N MAIN ST STE 304
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32218-2273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-955-2706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13453 N MAIN ST STE 304
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32218-2273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-955-2706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED MASSAGE THERAPIST/OWNER
-----------------------------------------------------
Name | TARA LESTER
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 904-955-2706
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------