=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447548516
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TIMELESS INNERGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2011
-----------------------------------------------------
Last Update Date | 07/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4614 WILGROVE MINT HILL RD SUITE C-11
-----------------------------------------------------
City | MINT HILL
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28227-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-681-7671
-----------------------------------------------------
Fax | 704-681-7671
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13809 SUMMIT COMMONS BLVD APT R
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28277-0439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-681-7671
-----------------------------------------------------
Fax | 704-681-7671
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/NEUROMUSCULAR THERAPIST
-----------------------------------------------------
Name | MS. FOXYRAE CAMPBELL
-----------------------------------------------------
Credential | LMBT
-----------------------------------------------------
Telephone | 704-681-7671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 11113
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------