=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437687688
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MADELEINE MARIE SANTORO LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2017
-----------------------------------------------------
Last Update Date | 06/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 RENWICK AVE
-----------------------------------------------------
City | KINGS PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11754-3730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-663-5555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 ELTON DR
-----------------------------------------------------
City | EAST NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11731-6008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-327-0812
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 030265
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------