=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447014188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORA MASSAGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2024
-----------------------------------------------------
Last Update Date | 02/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2353 RICE ST
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-3739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-283-6107
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 312 WHEELOCK PKWY E
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55130-3008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-283-6107
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MASSAGE THERAPIST
-----------------------------------------------------
Name | PAUL KONG
-----------------------------------------------------
Credential | CMT, LMT
-----------------------------------------------------
Telephone | 651-283-6107
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------