=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457953697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN SANDERS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2020
-----------------------------------------------------
Last Update Date | 11/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4820 E CABALLERO CIR APT 2
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85205-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-241-3509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 26723
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85285-6723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-241-3509
-----------------------------------------------------
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 | MT-04435P
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------