=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538515002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL FOSTER'S MASSAGE STUDIO, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2016
-----------------------------------------------------
Last Update Date | 05/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19111 W 10 MILE RD SUITE 224
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-2417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-400-2052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19111 W 10 MILE RD SUITE 224
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-2417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ LMT
-----------------------------------------------------
Name | ANGEL FOSTER
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 727-400-2052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | MA58664
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------